SPECIAL REPORT: PSYCHOCARDIOLOGY
When considering the relationship between mental and cardiovascular health, most conversations focus on negative emotions and related disorders, such as depression. This is not surprising, given that depression is common and associated with the development and progression of cardiovascular disease.1 This relationship is so strong that the American Heart Association considers it to be a risk factor for poor outcomes after a myocardial infarction,2 and this relationship has been the basis for depression treatment programs for patients with heart disease.
Although identifying and managing depression in patients with heart disease is important, focusing solely on negative psychological constructs has a downside. Since major depressive disorder affects only approximately 15% of patients with heart disease,1 depression treatments are applicable only to those 15% of individuals who suffer from that psychiatric illness. This raises the question of whether there are ways for psychiatrists to help all cardiac patients—not just those with depression or anxiety—feel better both emotionally and physically.
Research into well-being and related constructs may provide an answer. In the past 10 to 15 years, researchers have begun to identify relationships between well-being constructs (eg, optimism, positive affect) and cardiovascular health. In individuals without heart disease, these constructs are associated with a reduced risk of heart disease and all-cause and cardiovascular mortality.3,4 Among those with established heart disease, well-being constructs reduce one’s risk for major adverse cardiac events and mortality.3 Importantly, these relationships are independent of medical comorbidities, sociodemographic factors, and—oftentimes—depression.3
Well-Being and Heart Health
Both biological and behavioral mechanisms may explain the relationship between well-being and cardiovascular health. Positive psychological constructs are linked with physiologic processes that have been implicated in heart disease. This includes better autonomic functioning (ie, reduced sympathetic activation and increased parasympathetic activation), lower levels of inflammation, improved endothelial function, and lower levels of cortisol in some, but not all studies.3 There is even greater evidence for the relationships between well-being constructs and cardiovascular health behaviors. Positive constructs are prospectively and independently associated with more physical activity, a healthy diet (eg, more fruits and vegetables), medication adherence, engagement in treatment programs that promote cardiac recovery (eg, cardiac rehabilitation), and smoking cessation.3
IN THIS SPECIAL REPORT
Exploring Integrated and Collaborative Care
Special Report Chair, Michelle Riba, MD, MS
Positivism and Heart Health: Issues for Psychiatrists
Christopher M. Celano, MD, and Jeff C. Huffman, MD
The ABCs of Cardiac Screening and Electrocardiography
Margo C. Funk, MD, MA, and Theodore A. Stern, MD
More online:
The Cardiovascular Consequences of Drug Use
Craig J. Beavers, PharmD, FACC, FAHA, FCCP, BCCP, BCPS-AQ Cardiology, CACP
Understanding the QTc
Margo C. Funk, MD, MA, and Junyang Lou, MD, PhD
Treatment Dilemmas in Depression and Coronary Heart Disease
Lawson Wulsin, MD, and Juliana Zambrano, MD
Can Well-Being Be Cultivated?
Recent research suggests that well-being may be enhanced through interventions that focus on the reduction of stress, enhancement of calmness or relaxation, and promotion of positive psychological constructs. Meditation, mindfulness training, yoga, tai chi, and other integrative therapies can induce states of relaxation and calmness and can be incorporated into daily life. These types of interventions appear to be effective at reducing stress, depression, and anxiety in patients with vascular disease (including cardiovascular disease) or heart failure.5,6 Some studies have found these interventions also improve exercise capacity7 and downstream cardiovascular outcomes, such as hospitalizations.6
Positive psychology interventions, which emphasize the systematic completion of activities to cultivate positive psychological constructs, have become increasingly popular.8 These activities are simple to perform and may include writing a letter of gratitude, using a strength in a new way, or imagining a best possible future for oneself. These interventions have been studied in thousands of individuals and consistently improve well-being and reduce depression.9 Some interventions also have been shown to improve cardiac health behaviors, such as physical activity and medication adherence,10,11 when delivered alone or in combination with health behavior change interventions (eg, motivational interviewing). There have been preliminary positive results for in pilot trials for acute coronary syndrome,12 heart failure,13 type 2 diabetes,14 and other cardiac-related conditions.
Although randomized trials for integrative and positive psychology interventions are needed, promoting well-being in individuals with heart disease (and, really, in anyone) makes intuitive sense. Many of the positive constructs—such as mindfulness, relaxation, optimism, gratitude, kindness, life purpose—that these interventions aim to cultivate are things that anyone would benefit from experiencing more frequently. These interventions provide a system or framework to change one’s mindset from focusing on negative things in our lives to savoring and enhancing the positive experiences we have and setting ourselves up for more.
Cultivating Well-Being
Psychiatrists are well positioned to help all patients cultivate well-being. For example, if asked to consult on a patient with significant anxiety following a cardiac event, psychiatrists can teach the patient to use mindfulness (eg, relaxation response training, guided visualization). A patient with heart failure who is demoralized due to the severity of their symptoms can be encouraged to focus on those tasks they can still perform and have meaning to shift their focus positively. Finally, individuals who are recovering from cardiac events who are struggling to increase health behaviors can benefit from focusing on positive future outcomes and the use of strengths to reach their health behavior goals. The goal is to help patients reduce stress, use their strengths to approach challenges, and recognize positive events that are happening around them.
Preventing Burnout
Well-being is important not only for patients but also for physicians, who frequently work under stressful conditions and experience high levels of burnout. Fortunately, there are many simple ways to promote well-being (Table 1). This could include setting aside time to engage in an enjoyable or meaningful activity, making a point to discuss a positive event with a family member or friend, thinking about one aspect of the day for which you are grateful before going to bed, or using the strength of perseverance to work toward a life goal. It could also involve incorporating meditation or prayer into routines, or setting aside time for health behavior activities, such as exercise. Although many of these things seem simple, they are easily overlooked, and engaging in them regularly can help you develop habits that can have mental and physical health benefits.
Many free or inexpensive resources related to positive psychology, mindfulness, meditation, yoga, etc, can be found online. Table 2 contains a sample of the websites, podcasts, and mobile applications to help begin this positive journey. Although the number of available resources can seem overwhelming, it can be helpful to try a few different resources to see which ones work best.
Concluding Thoughts
Well-being and its related constructs are increasingly identified as being important components of cardiovascular health. Cultivating positive psychological constructs is possible through simple-to-perform exercises, and psychiatrists are in a unique position to help patients with and without heart disease feel more positive and hopeful. This, in turn, can have substantial effects not just on mental health, but on health behaviors and downstream physical health outcomes as well.
Dr Celano is associate director of the Cardiac Psychiatry Research Program and Massachusetts General Hospital (MGH) assistant professor of psychiatry at Harvard Medical School. Dr Huffman is a professor of psychiatry at Harvard Medical School and the director of the Cardiac Psychiatry Research Program in the Massachusetts General Hospital (MGH) Division of Psychiatry and Medicine. He also serves as the associate chief for clinical services in the Department of Psychiatry at MGH and the director of Inpatient Psychiatry Research at MGH.
References
1. Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression and cardiovascular disease: a clinical review. Eur Heart J. 2014;35:1365-1372.
2. Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation. 2014;129:1350-1369.
3. Dubois CM, Beach SR, Kashdan TB, et al. Positive psychological attributes and cardiac outcomes: associations, mechanisms, and interventions. Psychosomatics. 2012;53:303-318.
4. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med. 2008;70:741-756.
5. Abbott RA, Whear R, Rodgers LR, et al. Effectiveness of mindfulness-based stress reductions and mindfulness based cognitive therapy in vascular disease: A systematic review and meta-analysis of randomised controlled trials. J Psychosom Res. 2014;76:341-351.
6. Aggarwal M, Bozkurt B, Panjrath G, et al. Lifestyle modifications for preventing and treating heart failure. J Am Coll Cardiol. 2018;72:2391-2405.
7. Desveaux L, Lee A, Goldstein R, Brooks D. Yoga in the management of chronic disease: a systematic review and meta-analysis. Medical Care. 2015;53:653-661.
8. Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. American Psychologist. 2005;60:410-421.
9. Bolier L, Haverman M, Westerhof GJ, et al. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health. 2013;13:119.
10. Peterson JC, Charlson ME, Hoffman Z, et al. A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention. Arch Intern Med. 2012;172:329-336.
11. Ogedegbe GO, Boutin-Foster C, Wells MT, et al. A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans. Arch Intern Med. 2012;172:322-326.
12. Huffman JC, Feig EH, Millstein RA, et al. Usefulness of a Positive Psychology-Motivational Interviewing Intervention to Promote Positive Affect and Physical Activity After an Acute Coronary Syndrome. Am J Cardiol. 2019;123:1906-1914.
13. Celano CM, Freedman ME, Harnedy LE, et al. Feasibility and preliminary efficacy of a positive psychology-based intervention to promote health behaviors in heart failure: the REACH for Health study. J Psychosom Res. 2020;139:110285.
14. Huffman JC, Golden J, Massey CN, et al. A positive psychology-motivational interviewing intervention to promote positive affect and physical activity in type 2 diabetes: the BEHOLD-8 controlled clinical trial. Psychosom Med. 2020;82:641-649.❒
