Common Mental Health Problems In Heart Failure

Common Mental HealthProblems in Heart FailureRitu KalsiSenior Health Psychologist &Cognitive Behavioural Psychotherapistin Cardiac Health & RehabilitationOctober 2019

Learn about commonconditionsLook at prevalence & statsWhat are wegoing to do?Small group work & skillsharingAsk any questions

Why Do We Need ToKnow About MentalHealth Problems InHeart Failure?

Facts and Figures – Depression & AnxietyHeart failure is common and a major cause of death and disabilityDepression is common in heart failure (prevalence 21.5%)Depression is associated with:poor quality of lifelimited functional statusincreased risk morbidity and mortality in this populationAnxiety is also common in heart failure (prevalence 13.1% for anxiety disorders, 28.79% for probable clinicallysignificant anxiety, and 55.5% for elevated symptoms of anxiety (Easton et al., 2016))Anxiety is associated with:Poorer self-management behavioursIncreased symptom perception i.e. breathlessness, panic and chest-pains which can further exacerbatesymptoms of CHFincreased health-care utilisationMore than 30% of individuals with 1 or more physical long-term conditions have a comorbid mental healthconditionE.g. anxiety and depressionThis can lead to:Increased health complicationsConsumption of healthcareAnd, in turn, estimated increases in healthcare spending of 45%

Physical Health and Mental Health LinkThe mind and body is intricately connected through physiological and neurological pathways.Our emotional states affect our perception of physical symptomssuch as pain and breathlessnessOur stress levels affect the balance of systems in our bodies responsible for flight or fight andrecoverye.g. an anxious emotional state can increase feelings of breathlessness Depression and anxiety often affect motivation and confidence to engage in treatment such asrehabilitationThis can lead to poor self-management and inactivityAround 50% of patients with LTCs take their medications as prescribedOn the other hand, physical ill-health often leads to increased stress and a sense of loss ofidentity, independence, control and even relationships.Our environment, social connections and culture also play an important role in how we cope withmental and physical stressors

The overlap between long term conditions and mentalhealth problem 2012Long term conditions: 30%population of England(approx15.4 million ppl)Mental healthproblems: 20%population ofEngland(approx 10.2million ppl)30% peoplewith longterm willhave mentalhealthproblem46% of people withmental health problemhave long termconditionsSource: Long term conditions and mental health 2012- Naylor C, Parsonage M, McDaid D et tal

DepressionCommonMentalHealthProblemsin HeartFailureAnxiety

What have I doneto deserve thispunishment!?I amgoing todie soon!I messed up mylife and reacheda point of noreturn.I can’t even dochores withoutfeelingbreathless I amuseless!COMMON NEGATIVETHOUGHTSI’d ratherdie than bea burden tomy familyI am not theman I used tobe. I can’t evenplease my wifeI will get a shockanytime!I don’t need allthese meds, as longas I live a healthylifestyle I should befine

Stages in psychological adaptationto serious illnessInitial Crisis StageDenial predominates (may fluctuate betweenindifference and intense emotions, can’t retain muchinformation)Transitional StageAlternating feelings of guilt, anger, self-pity, andanxiety, rumination about past behaviour.Depression, suicidal ideation and lashing out iscommonAcceptance StageBegins to form a new identity integrating theacceptance of the illness and its implications. Reassess values, new sense of spirituality, begin to focuson quality rather than quantity of yearsPreparatory StageFear of becoming too dependent on others, take careof unfinished business. Need to discuss feelings ofdying and death

Evidence base (NICE Guidelines CG 91)3DLCPsychological Services:IAPTTheWellbeingHub forSocialsupportENHANCEDUSUAL CARETRAINING VIAIMPARTs

What isdepression?

The severity of depression can vary short term reaction an adverse event a prolonged episode that interferes with the ability to function,feel pleasure or maintain interestCommon symptoms include:Depression low moodfeelings of hopelessness and helplessnessfeeling useless, inadequate or badfrequent tearfulnessloss of appetiteloss of interest and pleasure in activitiesloss of energy and motivationagitation and restlessnessphysical aches and painsbeing vulnerable and over-sensitivesuicidal ideation/acts of self harm or suicide

Complexity of Depression Diagnosis inHeart FailureThe prevalence of major depression in chronic heart failure (HF) is about 20–40 %which is 4–5 % higher than in the normal population (Mills et al, 2017)Adverse effects of depression in HF patients include:Reduced quality of lifeReduced healthcare useRehospitalisationIncreased mortalityOverlap between psychological reactions to life-threatening illness and the onset of adepressive syndromeMisassumptions that depressive states are “normal” in response to medical illnessUnreliability of vegetative symptoms (e.g. weight, fatigue, weakness)Overlap with the effects of impaired cognitive functioning secondary to the medicalcondition itself

What isAnxiety?This Photo by Unknown Author is licensed under CC BY-NC-ND

Anxietysymptoms:MINDLow ConcentrationFeeling of dread and impending doomFeeling tired or fatiguedFeeling worried all the timeDisturbed sleepWithdrawalFeeling irritable

Anxietysymptoms:IN THEBODYFast or irregular heartbeatTightness in chestSweatingRapid breathing and hyperventilationDry mouthMuscle tension & pains in bodyTremblingNumbness & tingling in fingersFeeling faint and dizzyUrinating frequentlyIndigestionNausea, abdominal discomfort and stomach cramps

Generalised anxiety disorder (GAD)Obsessive compulsive disorder (OCD)Health AnxietyAnxietyDisordersinclude:Panic disorderPost traumatic stress disorder (PTSD)Social anxiety disorderSpecific phobiasSeparation anxiety disorder

Complexity of diagnosing anxiety in HFpatients:Anxiety DisordersTRIGGERA Panic DisorderAssessing anxiety within physical disease process can be a greatchallengePhysical and emotional conditions share many common symptomsincluding fatigue, palpitations, chest pains, breathlessness, andmany more (Easton et al, 2013)So.Measures used to identify anxiety must be appropriate for use in thispatient populationOmitting somatic items in the detection of anxiety should allow forthe separation of the emotional condition from the physical.

Exercise 1 - in groups of 4/5Based on your clinical experience of working with HF patients, howdo you make a differential diagnosis between a cardiac episode andan anxiety episode? Bear in mind they could be both In your experience what are the tell tale signs that help youdifferentiate?

Exercise 2 – in groups of 4/5As specialist HF nurses, have you had any difficult encounters withpatients who are resistant to accept that their symptoms areconsistent with an anxiety/panic disorder? How have you managedthis?

Management of panic disorder:Differentiate between anxiety episodes and symptoms of HFScreening tools – PHQ-9 and GAD-7 to detect symptoms (less invasive)Look a Hx of panic attacks in the past (onset?). Does this coincide with their health issues or longbefore they had the HF?Do not jump to conclusions as there is a risk of invalidating their medical symptoms (invasivetests)Remain respectful but still maintain your point of view – be assertiveProvide them with some psychoeducation on anxiety (resources can be found at the end of thispresentation)Tell the patient to at least try to manage the anxiety and see what the residual is

GAD-7

PHQ-9

Questions to ask your patientsDuring the past month:Have you often been bothered by feeling down, depressed or hopeless?Have you often been bothered by having little interest or pleasure indoing things?Have you often felt unable to stop worrying or that you were worryingtoo much?Have you often felt nervous, anxious or unable to relax?

CognitiveComponentsOf PhysicalResponsesBehaviourFeelings

Simple rules to manage panic and anxietyAssert the fact that the feelings are normal bodily reactionsThey are not harmful, just hugely unpleasantDo not add frightening thoughts about what may or may not happenWait for the fear to pass, do not fight it or run away from itNotice what is really happening in your body right now, not what youfear might happenNotice that once you stop adding frightening thoughts, the fear willstart to fadeThe whole point of this is to learn to tolerate and manage the fearrather than avoid it

Breathing Techniques & MindfulnessPeople who are anxious tend to breathe in their upper lungs (upper chest) with shallow, rapidbreaths, instead of breathing into their lower lungs (lower chest).This is one contribution to hyperventilation: shallow, upper lung breathing.By changing their breathing they can reverse these symptomsShifting breathing rate and pattern, can stimulate the body's parasympathetic responseThis is the body's opposite system to the Emergency Response and is often called theRelaxation Response.This is a state of profound rest that can be elicited in many ways, including:Progressive Muscle RelaxationDiaphragmatic BreathingMindfulnessYogaMeditation5 minute Breathing Exercises:https://www.youtube.com/watch?v YFSc7Ck0Ao0https://www.youtube.com/watch?v nmFUDkj1Aq0

ResourcesCentre for Clinical .au/Resources/For-Clinicians/PanicHealth /For-Clinicians/Health-AnxietyIncludes: breathing retraining, relaxation, breathing rate record, progressive muscle relaxation, coping with stressHeart Failure Mattershttps://www.heartfailurematters.org/en tyGet Self Helpwww.getselfhelp.co.ukLiving Life To The Fullhttps://llttf.com/Includes ‘Living with a Long Term Condition’ and ‘Living Life To the Full with Coronary Heart Disease’ coming /indexMain#.XZSVV0a2mBY

Thank youAnyQuestions?

Generalised anxiety disorder (GAD) Obsessive compulsive disorder (OCD) Health Anxiety Panic disorder Post traumatic stress disorder (PTSD) Social anxiety disorder Specific phobias Separation anxiety disorder