Psychiatric Aspects of Heart Disease

by Diana Hughes, MD

About 5 million Americans suffer with Heart Disease. Each year, approximately 500,000 people will suffer a heart attack, many of whom will come face to face with their own mortality for the first time in their life. A cardiac event, whether it is a heart attack, an arrhythmia, heart failure, or surgery, has a tremendous impact on an individual, both physically and often emotionally. More often than not, this has ramifications for the spouse, family, friends and work situation.

When the initial trauma is over, the patient with heart disease has been stabilized and doctors are beginning to talk about the individual returning to work and resuming a normal lifestyle. However, many patients and their families continue to suffer. Even in the absence of physical limitations imposed on an individual because of heart disease, many people function at a lower level and have a reduced quality of life. Those individuals with limitations often function at a reduced capacity, even when their restrictions are accounted for. Why is this?

Depression

Today we know that the chance of an individual with heart disease suffering with depression is at least three times greater than for someone without heart disease. This is important, because studies have shown that a person with heart disease and depression has a one and a half to three times increased risk of actually dying six months to eighteen months after suffering a heart attack. They are also at increased risk for another heart attack, an arrhythmia and other complications of heart disease. Depression will also interfere with an individual's ability to make the necessary lifestyle changes that heart disease demands, such as losing weight, stopping smoking and exercising regularly. Symptoms such as a persistently depressed mood, lack of interest in previously enjoyed activities, social withdrawal from friends and family, sleep or appetite changes, decreased energy, hopelessness, excessive guilt, or thoughts of not wanting to live anymore, should be brought to the immediate attention of the treating doctor.

Anxiety

Many patients with heart disease develop anxiety after an acute cardiac event. Fears of dying, or fears of suffering another heart attack, being unable to provide for family etc., are common. Some studies even suggest that there is an increased risk of complications and dying in those patients who are very anxious, have phobias, or panic attacks, together with heart disease. The literature is not, however, conclusive. Some patients who have undergone cardiac surgery, or had a cardiac arrest at the hospital, suffer with flashbacks and recurrent nightmares of these events, and can develop Post Traumatic Stress Disorder. Any anxiety symptoms that are causing distress to a patient with heart disease should be brought to the attention of the treating doctor.

Marital Functioning

The impact of an acute cardiac event on a marriage can serve to strengthen or weaken a relationship by virtue of the crisis it creates. Many spouses feel that they have been inadequately informed, educated or involved in the acute hospital treatment, which can lead them to be inadequately prepared for living with a partner with heart disease in the home setting. The spouse needs to be able to confront the patient if they are not compliant with medication, lifestyle changes etc., without feelings of fear, guilt and frustration. If the patient is poorly compliant with the medical regime, spouses often feel angry, frightened and powerless, and the marriage suffers. Sexual activity often declines for a variety of reasons-e.g. thirty to forty per cent of women with heart disease report never returning to full sexual activity. Marital and sexual problems once identified are easily amenable to treatment with a qualified individual.

Work

Significant numbers of patients with heart disease receive social security and disability payments as a result of the physical and emotional complications of heart disease. The estimated financial burden to the USA economy for 1999 as a result of this was 286.5 billion dollars. Men with heart disease are more likely than women to return to work. There is often a high degree of work turnover in the 62-90% of patients with heart disease, who do, initially at least, return to work. Many reduce from full-time to part-time employment, and others take early retirement. Such decisions are often independent of the severity of heart disease, and can be linked to insufficient treatment of the emotional aspects of heart disease in some cases.

Compliance with Medical Treatment

Compliance with medical treatment is paramount for an individual recovering from an initial cardiac event, in order to live with heart disease in a manner that provides the patient with the best quality of life both physically and mentally. Compliance however, is often elusive. 50-80% of heart attack survivors return to previous unhealthy lifestyle patterns, despite having received some education and having embarked on behavior modification programs for weight loss, smoking cessation, exercise etc.

Factors that help facilitate compliance include partner and family support, peer and physician support, and psychological well-being.

ABOUT THE AUTHOR:
Diana Hughes M.D. is the Medical Director of Out-Patient Consultation Liaison Psychiatry at Long Island Jewish Medical Center. She attended medical school in England, where she trained in Family Medicine, before coming to the United States to train as a Psychiatrist. Dr. Hughes completed her residency training in Psychiatry at Hillside Hospital, where she also served as Chief Resident in her final year. Honors have included two national fellowship awards, from the Association of Academic Psychiatry, and the American Psychoanalytic Association. Dr. Hughes then received subspecialty training in Consultation Liaison Psychiatry at Long Island Jewish Medical Center, and is currently on Faculty at the same institution. She has been a member of the APA since the beginning of her residency, served as Member-in-Training Representative to the Greater Long Island Psychiatric Society's (GLIPS) Board of Directors, and currently is the GLIPS Representative to the APA Assembly, as well as the Area II Early Career Psychiatrist Representative to the APA Assembly. Dr. Hughes is married with one daughter, and is expecting a second child in April.