Professor Myra Hunter Institute of Psychiatry, KCL Consultant clinical psychologist,

1. Meeting the psychological needs of cardiac patients – an integrated stepped-care approach within a Cardiac Rehabilitation setting Professor Myra Hunter Institute of Psychiatry, KCL Consultant clinical psychologist, South London & Maudsley Trust

2. Depression and cardiac disease • Prevalence of depression in cardiac patients 3 times higher than general population • 25-30% persistent anxiety/depression • Depression in cardiac patients is a significant and independent predictor of mortality, increased cardiac events, reduced quality of life, poorer self-management and greater health service use

3. Depression: pathways to CHD Biological changes Indirect Health behaviours (e.g. exercise) Depression/ Anxiety (Stress) CHD Biological changes (e.g. heart rate variability) Direct (Adapted from Brunner, 2002)

4. Depression and cardiac disease • Socio-economic disadvantage associated with depression and CHD • The death rate from CHD is 38% higher for men and 43% for women born in the Indian sub-continent • Living alone, being socially isolated, low emotional support, lack of a confidante additional independent predictors of morbidity and mortality • Services may not meet women’s needs

5. Cardiac Rehabilitation: meeting the needs • Cardiac rehabilitation (CR): multidisciplinary group based sessions aimed to improve physical and emotional recovery • Typically includes: health education (smoking, diet, exercise), stress management, exercise, delivered by cardiac specialist nurses, physiotherapists, dieticians - 6 weeks • NSF recommends that 85% attend a CR programme • Depression, lower SES associated with lower take up and higher drop out rates

6. Cardiac Rehabilitation: meeting the psychological needs • Psychosocial interventions advocated by NSF (2001) and NICE (2007) • Evidence for psychological and medical interventions for depression in cardiac patients: mixed generally no effect on cardiac outcomes • Enrichd trial 2003: CBT reduced depression after 6 mths but not sustained at 30 mths - one size fits all CBT… • Cochrane review 2004: CBT no effect on mortality but some effect on anxiety/depression • Meta-analysis 2007: CBT in first 2 years reduced mortality in men but timing important no effect if offered immediately after cardiac event

7. British Heart Foundation audit of UK CR 2009 • 4% reduction in anxiety/depression (HAD) following CR • 33% of UK CR programmes have some psychology • 3% included psychological interventions

8. Meeting Psychological Needs of Cardiac Patients Funded by Guys & St Thomas’ Charity to GST and SLAM 3 year project Service innovation to integrate psychology within multi-disciplinary cardiac rehabilitation programme Provide & evaluate a stepped care approach with interventions that are individualised and acceptable and accessible for patients To carry out service evaluation

9. Alison ChildCardiac Liaison SisterJane SandersCardiac Rehabilitation SisterPaul Sigel Consultant Clinical Psychologist Myra Hunter IOP/SLAMB J Cardiology 2010;17:175-9.

10. Clinical psychologists role Specialised psychological interventions Improving access to and acceptability of psychological interventions Input to CR programme Multidisciplinary work - collaboration with physicians, nurses & therapists (including prevention) Training, supervision, research

11. Access points to clinical psychology during the patient journey Psychological assessment & treatment GPs Liaison with IAPT CMHT Cardiac Event Heart Failure team Hospital Discharge S1 Home Visit S2 Cardiac Rehab S3 Cardiac Out Patients S4

12. Psychological Interventions Stepped-care Approach Intervention Patient need IndividualTherapy High Group Workshops/ Brief 1:1 therapy Moderate Psycho-education sessions Mild

13. Psychological interventions • Psycho-education sessions within the cardiac rehabilitation, addressing on behavioural risk factors and adjustment issues. Co-facilitated with other members of the MDT • Brief individual therapy 1-6 sessions. This included cardiac-focused/ engagement focussed interventions and included people with severe SMI • Individual therapy 4-26 sessions CBT for anxiety, depression and adjustment to adverse life events • Group workshops consisting of eight sessions for small groups (3-8 patients)

14. Adjustment, depression, anxiety and behavioural risk factors • Concerns about the meaning and impact of symptoms • Disbelief and non acceptance of cardiac problem • Health beliefs and catastrophic interpretations about impact of cardiac disease on their lives and in the future • Coping and engaging in everyday activities • Adherence to treatments • Modifying behavioural risk factors smoking, alcohol, exercise, weight • Changes in roles, relationships and interactions with other people • The re-emergence or intensification of pre-morbid psychological difficulties • Noticing some benefits

15. Results: accessibility and acceptability • 103 (82%) of the 125 patients referred accepted interventions from the psychologist • Gender (62% male and 38% female) and ethnicity (70% White, 10 Black, 8% Asian, 7% other and 6% not recorded) was similar to that of patients attending cardiac rehabilitation.

16. Psychological interventions delivered to patients

17. Mean scores on the BDI showing changes in mood after psychological interventions

18. Results Audit data for 460 patients attending CR during the two years of the study (2005-2007) showed a reduction of 19% for anxiety and 13.5% for depression (HADS) following the CR compared to a 4% national average (National Audit of Cardiac Rehabilitation, BHF, 2009) Overall satisfaction rates (Client Satisfaction Questionnaire) on discharge of 86% for all intervention types, ranging from 83 to 93%. Psychological input acceptable and accessible Depression reduced in those treated (BDI)

19. Conclusions • Integration of psychology within the MDT in the acute setting enabled increased accessibility and acceptability • This also reduced possible stigma and normalised the focus on psychological issues • The psychologist provided the team with supervision and support in addressing psychological issues • The flexible timing and the emphasis on patient choice of the level of intervention were felt to be important elements of the service.

20. Future directions IAPT Community Evaluation of groups (Tylee et al in progress) Collaborative care (Katon et al New Eng J Med 2010) Cardiac settings: non cardiac chest pain, anxiety in people with implantable cardiac defibrillators (ICDs), input to heart failure and Cardiac Rehab teams