Page 799 - Cardiac Nursing

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C HAPTER 33 / Psychosocial Risk Factors: Assessment and Management Interventions 775
Knowing that CHD patients can have one or more of the above- modifying their psychosocial risk factors. The ENRICHD study
mentioned psychosocial manifestations, nurses should refer pa- showed that patients’ interest in treatment waned after awhile and
tients who meet the above diagnostic and assessment criteria to a that they often wanted to put the experience of their cardiac event
licensed mental health professional for a complete “work up” and behind them. 119 Thus, the critical time for intervention is within
the initiation of appropriate treatment. the first few months after an event when patients might still be
motivated to make lifestyle changes. Most patients are receptive to
education during the acute phase of a cardiac event. These inter-
PSYCHOSOCIAL ventions can provide a sense of control, decrease anxiety, and im-
INTERVENTIONS IN CHD prove self-efficacy. The psychosocial management interventions
described in the following section target physiological arousal,
Most research on psychosocial interventions has examined their ef- negative behaviors, and negative attitudinal cycles. Nurses are ide-
fects on decreasing cardiac morbidity and mortality. The mixed re- ally suited to teach patients about these interventions.
sults or small effect sizes from such inquiries in the last decade have
been attributed to insufficient sample sizes; individual versus group- Self-Monitoring Negative Reactions
based interventions; heterogeneous targets of intervention— and Responses
behavioral, physiological, or emotional distress reduction; variable
length of treatment; and lack of biological or cardiac endpoints as With any intervention, nurses must determine how self-aware pa-
outcome variables. 87,114 ENRICHD, a multicenter, randomized, tients are of their behaviors and emotions. Acute coronary events
controlled clinical trial, was the first large study to evaluate the ef- are overwhelming and can lead to denial, 119 making it difficult for
fect of an intervention designed to reduce depression and improve patients to understand their reactions to such an event. Even be-
social support on reducing CHD morbidity and mortality. Al- fore an acute event, many patients are not attuned to or are un-
though the study’s sample of 2,481 MI patients included a broad comfortable with their emotional reactions, if they are considered
distribution of age, gender, ethnicity, and race, it was unable to harmful or unimportant. 120 Although it can be a useful coping re-
3
demonstrate that treatment had a “mortality benefit.” The study, sponse in the short term, denial, if it persists, can lead to avoid-
however, did show a statistically significant reduction in depres- ance or minimization of symptoms and lackadaisical effort in
sion and improvement in social support, which improved the making lifestyle changes. 121,122 Also, it can lead to unchallenged
quality of life for those patients who received psychosocial inter- negative assumptions and negative emotions that foster increased
vention. Taylor 115 observed that the reduction in rates of death helplessness and hopelessness, impeding problem solving and pos-
and reinfarction in the control and treatment groups as a result of sibly leading to social disconnectedness.
early and aggressive treatment with cardiologic agents may have Cognitive-behavioral treatment enables patients to understand
made it difficult to discern differences between the two groups. their reactions and to modify assumptions that lead to negative
Another study, Sertraline Antidepressant Heart Attack Random- emotions and behaviors. This short-term structured treatment,
ized Trial (SADHART), conducted concurrently to test if phar- which can be administered to individuals or groups, concentrates
macological management of depression alone could reduce CHD on current problems to develop mood management skills, new
mortality, also failed to show improved survival. 116 Taylor, 115 strategies to handle difficult situations, and self-therapy skills and
however, noted that in the ENRICHD study the risk of death and can be applied to problems related to anxiety, anger, maladaptive
recurrent MI was lower for those taking sertaline and receiving behaviors besides depression, social isolation, and stress. 123 Cog-
psychosocial interventions. Despite the mixed results, the role of nitive behavior therapyy y 23 is an effective treatment for depression
depression and social support in the development and mainte- and evidence-based guidelines recommend its use for mild to
nance of cardiac disease is well established. Thus, developing and moderate depression. 124,125
implementing psychosocial interventions to modify behavioral Several studies of cardiac patients including ENRICHD 3,11,
risk factors, decrease emotional distress (particularly depression), 120,126–128 have used cognitive behavioral therapy (a) to raise pa-
and improve quality of life are considered vital adjuncts to cardiac tients’ awareness of automatic assumptions about the MI, self,
medical and surgical procedures. 3,87 Future trials, however, should others, and the world; (b) to implement strategies and skill build-
track both physiological markers and changes in depressive symp- ing that improve mood by evaluating assumptions, engaging in
toms, because correlating changes in depression and cardiovascular positive behaviors, practicing behavior drills, and improving in-
98
outcomes can be challenging. Researchers should also investigate teractions with others; and (c) to increase self-efficacy and self-
the effects of sustained intensity of treatment to address recurrent esteem. Cognitive behavioral therapy emphasizes that stressful
depression and to consider gender-specific treatments, 33 and the events, such as a coronary artery bypass graft or everyday stressors
complex relationship between depression and mortality following associated with recovery, can trigger negative reactions at multiple
an MI needs to be better understood to improve the timing of the levels: attitudinal (thoughts), behavioral, emotional, and physio-
depression intervention. 117 logical. For example, a successful entrepreneur who experiences
As patients recover from coronary events, nurses have many debilitating weakness following a coronary bypass surgery, may
opportunities to educate, motivate, facilitate, and provide psy- think “I am useless. I will never be able to work like before, I will
chosocial interventions. Such interventions should be initiated have to quit.” In such a state, the patient may become depressed,
while patients are still in the hospital, because the first few months experience fatigue, sleep excessively, and when home, refuse to
after a coronary event are critical for survival. An acute medical take his medication, exacerbating his physical symptoms. Nega-
crisis often motivates patients to consider lifestyle changes. For ex- tive thoughts may follow (Fig. 33-2).
ample, one study showed that smoking cessation rates among MI Once aware of their assumptions, patients might re-evaluate
patients were 70% compared with 9% for smokers in the general their cognitions and improve their mood by seeking reliable in-
population. 118 Similarly, CHD patients may be more receptive to formation. Conversely, a lack of awareness may lead to prolonged