Recognize and Enable Care for Post-MI Psychological Distress: AHA

Many patients wrestle with some form of mental health issues after an MI. A new scientific statement from the American Heart Association is urging cardiologists and other healthcare practitioners to embrace the importance of psychological health in recovery and well-being.

“There is a strikingly high incidence—somewhere between 33% and 50%—of negative psychological health or psychological distress in these patients,” said Glenn N. Levine, MD (Baylor College of Medicine, Houston, TX), who chaired the statement that was published online ahead of print in Circulation.

This includes anxiety, depression, psychosocial stress, and posttraumatic stress disorder (PTSD) after an MI, and data show strong associations in cardiac patients between these conditions and adverse outcomes, including a second MI or death. The committee refers to this cluster of conditions as post-myocardial psychological distress (PMPD).

Four years ago, Levine led an AHA initiative that laid out the available evidence linking psychological health, both negative and positive, with cardiac risk and outcomes. Individuals with persistent PMPD that lasts up to a year after an MI have been shown to have a 1.5-fold higher risk of a future cardiac event compared with those who don’t experience long-term stress after an MI. Certain patient characteristics were linked to heightened risk as well: being female; living alone; being unmarried, unemployed or an immigrant to the US; lacking social support; and having a history of mental health conditions or chronic illness.

To TCTMD, Levine said the purpose of the more-recent document is to provide tools and guidance to help with what can be a sensitive and daunting topic for some patients and their physicians after an MI, and to put PMPD on the radar so it can be prioritized by the cardiology community. Numerous guidelines from American and European societies do advocate for mental health assessments in CV care, the committee notes, ranging from discussion of the problem’s scope to formal recommendations.

“The most important thing is to be aware, because if you’re not aware that this is a problem you’re not going to recognize it,” he said.  ”The goal we emphasize in the paper is to be treating the patient as a whole, not just their heart.”

Gentle Hints and Simple Tools

Levine said a topic of significant discussion among the committee was the lack of data to support routine screening of all post-MI patients for PMPD. Some studies, like CODIACS-QoL, for example, have confirmed that systematic screening for depression was feasible in practice, but it didn’t lead to better quality of life or make a difference in depressive symptoms, possibly because a significant number of patients did not accept mental health treatment even when it was offered for free.

With a lack of evidence supporting routine mental health assessments, the committee provides simple options for physicians who are interested in screening their patients. Among the recommended brief, patient-administered screening tools are the 4-item Patient Health Questionnaire, the 5-item Primary Care PTSD Screen for DSM-5, and the 4-item Perceived Stress Scale.

“If routine screening is adopted, it is recommended that the approach includes an established pathway for additional, advanced assessment and psychological health treatment, and models are available for offering this integrated treatment within cardiovascular medicine,” the statement notes.

Levine and colleagues suggest gently broaching the subject of PMPD with patients by noting that they seem worried or stressed and asking if they have any interest in talking further with a mental health professional. The document also reviews common antidepressants as well as cognitive behavioral therapy and the available evidence for the benefits of both in patients with cardiovascular conditions.

 ”We don’t expect most cardiologists to start people on anxiolytic or antidepressant medications,” Levine said. “We just want them to be aware that there are very good programs that really can help people decrease the stress, and very good medicines that can improve their mood.”

There are very good programs that really can help people decrease the stress, and very good medicines that can improve their mood. Glenn N. Levine

The committee also points out that behavioral therapy options are widely available to patients online, a format might be appealing to some.

While certain aspects of mental health assessment and treatment are beyond the scope of what busy cardiologists can do, other things like cardiac rehabilitation may enter the conversation as an additional way to encourage emotional well-being through exercise, stress management education, and mindfulness. Additionally, some of these programs can refer patients to behavioral health specialists when needed.

However, Levine and colleagues note that despite being indicated for nearly all post-MI patients, cardiac rehab attendance is historically poor. “This appears to be a potential ‘low-hanging fruit’ by which patient prognosis can be improved and PMPD can be addressed,” they suggest.

For Levine and the committee, the most important thing is just having these conversations with patients about their mental and emotional well-being while remaining empathetic but not aggressive.

“You need to gently broach this with people with comments that are reflective,” Levine said. “You acknowledge that they seem down or they seem worried. You don’t confront them or challenge them about it.  You just sort of open the door to let them talk, and to let them feel that it’s a safe place to talk.”

Additionally, Levine said he never recommends referral to a psychiatrist because this can have negative connotations for many patients or make them unwilling to discuss the issue further, especially in front of a spouse or other loved one.

“I’ll always specifically use the term ‘mental health professional’ [because] it’s a much less intimidating way to broach things with people,” he added.