Transcript Chronic anxiety in ICD patients: A multi

CoRPS
Center of Research
on Psychology
in Somatic diseases
ICD patients with anxiety: what to do?
Susanne S. Pedersen, Professor of Cardiac Psychology
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Disclosures
Moderate speaker or consultancy fee from:
• Cameron Health
• Medtronic
• Sanofi-Aventis
• St. Jude Medical
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Affiliations
Prof.dr. Susanne S. Pedersen
• CoRPS - Center of Research on
Psychology in Somatic diseases, Tilburg
University, The Netherlands
• Thoraxcenter, Erasmus Medical Center,
Rotterdam, The Netherlands
• Department of Cardiology, Odense
University Hospital, Denmark
Phone: + 31 (0) 13 466 2503
E-mail: [email protected]
www.tilburguniversity.nl/corps
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Overview
• Prevalence of anxiety in ICD patients
• Which patients are at risk of anxiety?
• Why bother about anxiety in ICD patients?
• What to do about anxiety in ICD patients?
• Take home message
CoRPS
Overview
• Prevalence of anxiety in ICD patients
• Which patients are at risk of anxiety?
• Why bother about anxiety in ICD patients?
• What to do about anxiety in ICD patients?
• Take home message
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Prevalence of anxiety in ICD patients
• Anxiety ≈ 25%-33%
• Posttraumatic stress ≈ 12%-19%
• A high level of chronicity of anxiety at 12
months post implantation → 51.8% (115/222) of
patients anxious prior to ICD implantation
Kapa et al. PACE 2010 33;198-208; Versteeg et al. Int J Cardiol
2011;146:438-9; Pedersen et al. Int J Cardiol 2011;147:420-3
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Prevalence of anxiety in ICD patients
A subset of patients: 1 in 4 (25%)
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Overview
• Prevalence of anxiety in ICD patients
• Which patients are at risk of anxiety?
• Why bother about anxiety in ICD patients?
• What to do about anxiety in ICD patients?
• Take home message
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Prevalence of anxiety and depression in
patients stratified by Type D and shocks
N = 182
%
80
70
60
50
40
30
20
10
0
Type D - shocks
Non Type D - shocks
72
Type D - no shocks
Non Type D - no shocks
67
61
57
32
13
Anxiety
19
14
Depression
Pedersen, Jordaens, Theuns et al. Psychosom Med 2004;66:714-9
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Predictors of posttraumatic stress at
baseline and follow-up
N = 107
Von Känel et al. J Affect Disord 2011;131:344-52
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Correlates of anxiety and depression
Female gender
Age
Living with a spouse
Non-ischaemic etiology
Symptomatic CHF
Co-morbidity
ICD-related complications
ICD shocks
Years with ICD therapy
Current smoking
Amiodarone
Other antiarrhythmic medication
Psychotropic medication
Anxiety
OR [95% CI]
Depression
OR [95% CI]
2.38 [1.32-4.29]†
ns
ns
ns
5.15 [3.08-8.63]‡
ns
ns
2.21 [1.32-3.72]†
ns
ns
ns
ns
ns
ns
ns
ns
ns
6.82 [3.77-12.39]‡
ns
ns
2.00 [1.06-3.80]*
ns
ns
ns
ns
2.75 [1.40-5.40]†
* P < 0.05; † P < 0.01; ‡ P < 0.001
Johansen, Pedersen et al. Europace 2008;10:545-51
N = 610
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Overview
• Prevalence of anxiety in ICD patients
• Which patients are at risk of anxiety?
• Why bother about anxiety in ICD patients?
• What to do about anxiety in ICD patients?
• Take home message
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Anxious Type D patients and ventricular
arrhythmias
N = 391
van den Broek, Denollet et al. JACC 2009;54:531-7
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Posttraumatic stress symptoms and
mortality
N = 147
HR: 3.45 (95%CI: 1.57-7.60; p = .003)
Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30
Type D personality and high ICD preimplantation concerns and mortality
N = 371
HR: 3.65 (95%CI: 1.57-8.45; p = .003)
2-year mortality (%)
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20
18
16
14
12
10
8
6
18.2%
5.2%
4
2
0
Type D and concerns
Pedersen, Erdman et al. Europace 2010;12:1446-52
None or one risk marker
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ICD shock - the paradox
Stressed out…
Me ???!!
Braunschweig, Boriani, ... Pedersen et al., Europace 2010;12:1673-90
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•
•
•
•
ICD shock - the paradox
Cardiac psychology has
something to offer to patients
Reduce catastrophic
thinking
Alleviate symptoms of
anxiety and depression
Improve quality of life
Effect on survival?
Pedersen et al. PACE 2007;30:1546-54; Lewin et al. Heart 2009;95:63-9
Irvine et al. Psychosom Med 2011;73:226-33
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Overview
• Prevalence of anxiety in ICD patients
• Which patients are at risk of anxiety?
• Why bother about anxiety in ICD patients?
• What to do about anxiety in ICD patients?
• Take home message
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1. Screen and monitor
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Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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ICD Patient Concerns questionnaire
We want to know what things worry you about living with your ICD. It is important that you answer
every question. Don’t spend too long thinking about your answers. For each question please circle
one number. Please don’t leave any out.
0 = Not at all
1 = A little bit
2 = Somewhat
3 = Quite a lot
4 = Very much so
I AM WORRIED ABOUT......
1. My ICD firing
0
1
2
3
4
2. Doing activities/hobbies that may cause my ICD to fire
0
1
2
3
4
3. Time spent thinking about my ICD firing
0
1
2
3
4
4. Working too hard/overdoing things causing my ICD to fire
0
1
2
3
4
5. Having no warning my ICD will fire
0
1
2
3
4
6. The symptoms/pain associated with my ICD firing
0
1
2
3
4
7. Not being able to prevent my ICD from firing
0
1
2
3
4
8. Getting too stressed in case my ICD fires
0
1
2
3
4
Pedersen, Theuns, Jordaens et al. Am Heart J 2005;149;664-9
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2. Clinical practice tips
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Shock-induced distress – how does it
work?
Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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General measures
• Establish trustful relationship…
o
with patients and partners
o
with mental health expert inside or outside the team
• Listen to patients and leave room for questions and
emotions
• Look at patient’s body language
• Regularly explore beliefs, health resources and
distress (both pre-existing and newly developed)
Sears et al. Stress and Health 2008;24:239-48
Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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General measures
• Offer quick help if shocks and / or distress occur
• Ask for subjective effects of shock…
o
Sensory and emotional perception
o
Interpretation
o
Behavioral consequences
o
Encourage resumption of activities asap
• Explore patient needs for more information and
support
• Provide reassurance
Sears et al. Stress and Health 2008;24:239-48
Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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Specific measures
• ICD specific education
o
How the device works, triggers of shocks, how to respond to
shocks (e.g. shock plan [Sears et al. Circulation 2005;211:e380-2])
o
Everyday functioning (e.g. occupational limitations, physical
and sexual activity, driving)
• Multidisciplinary cardiac rehabilitation
o
“One size does not fit all”
o
Demonstrate safety of customized exertion via cardiac
rehabilitation approaches
Sears et al. Stress and Health 2008;24:239-48
Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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Specific measures
• Relaxation and stress management
o
Assist patients in reducing arousal via progressive muscle
relaxation and diaphragmatic breathing
• Cognitive restructuring (CBT)
o
Teach patients to value the ICD as a source of protection
rather than a threat to their well-being
o
Encourage activity planning and exposure-based exercises to
teach patients to engage in activities they have reduced or
avoided due to the device
Sears et al. Stress and Health 2008;24:239-48
Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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Specific measures
• Social support
o
Provide patients with social support via nursing contact,
patient calls and support groups
• Referral to a mental health professional
• Prescription of pharmacotherapy (e.g. SSRIs and
anxiolytics)
Sears et al. Stress and Health 2008;24:239-48
Braunschweig, Boriani, .... Pedersen et al. Europace 2010;12:1673-90
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E-health the future?
Pedersen et al. Trials 2009;10:120
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Overview
• Prevalence of anxiety in ICD patients
• Which patients are at risk of anxiety?
• Why bother about anxiety in ICD patients?
• What to do about anxiety in ICD patients?
• Take home message
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Take home message
• A subset (25%-33%) are at risk of psychological distress
• High-risk patients – symptomatic heart failure,
psychological profile, shock
• Distress increases the risk of VTs/VFs and mortality
• Screen and monitor – we need to know who they are;
this information cannot be extrapolated from medical
records
• Multi-factorial psychosocial/behavioral interventions
targeted to the individual most likely to be successful
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Device Conference, 3-4 November 2011,
Tilburg, the Netherlands
Living in a Device World: Focus on Recent Challenges and Tools to Improve
Clinical Care for Patients with an Implantable Cardioverter Defibrillator
Themes
Selection of invited faculty
• OVERCOMING THE SHOCK OF THE ICD
• Nico Blom (MD, PhD), Leiden University Medical Center, NL
• ICD REGISTRIES AND THE INCLUSION OF THE
PATIENT PERSPECTIVE
• Matthew Burg (PhD), Yale School of Medicine, USA
• DEACTIVATION OF THE ICD AND END OF LIFE
ISSUES
• Viviane Conraads (MD, PhD), University Hospital Antwerpen, BE
• Dorothy Frizelle (PhD), University of Hull, UK
• Jens Brockon:
Johansen, (MD, PhD), Odense University Hospital, DK
More information available
• Karl-Heinz Ladwig (MD, PhD), Helmholtz Institute, Munich, GE
CRT SELECTION AND RESPONSE
www.tilburguniversity.edu/device2011
• Mathias Meine (MD, PhD), University Medical Center Utrecht, NL
THE DO’S AND DON’TS OF PATIENT
• NEGLECTED SUBGROUPS
•
•
COMMUNICATION
• Susanne S. Pedersen (PhD), CoRPS, Tilburg University, NL
• SEXUALITY IN ICD PATIENTS
• Samuel Sears (PhD), East Carolina University, USA
• BEHAVIORAL INTERVENTIONS
• Steen Pehrson (MD, PhD), Copenhagen University Hospital, DK
• LOOKING INTO THE FUTURE
• Dominic Theuns (PhD), Erasmus Medical Center Rotterdam, NL