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C HAPTER 33 / Psychosocial Risk Factors: Assessment and Management Interventions 777
DISPLAY 33-1 A Classic Example of a Relaxation improving emotional states. However, what makes an activity sat-
Exercise isfactory is based on personal preference.
Exercise is a valuable intervention for depression in CHD pa-
Transcendental Meditation
tients. In one study, those who adhered to exercise had greater re-
1. Sit quietly in a comfortable position. ductions in anxiety and depression than nonadherers. 141,142 The
2. Close your eyes. relationship between adherence to exercise and improvement in
3. Deeply relax all your muscles, beginning at your feet psychological variables was also seen in a community study of older
and progressing up to your face. Keep them relaxed. adults. 143 Participation in exercise was related to lower depression
4. Breathe through your nose. Become aware of your and anxiety. 136 Thus, exercise training as an intervention has the
breathing. As you breathe out, say the word, “ONE,” dual benefit of improved cardiovascular health and self-esteem 131
silently to yourself. For example, breathe IN . . . OUT,
“ONE”; IN . . . OUT, “ONE”; etc. Breathe easily and and helps patients who are anxious or depressed. Patients and
naturally. their families must be taught about the benefits of exercise and en-
5. Continue for 10 to 20 minutes. You may open your eyes couraged to attend a cardiac rehabilitation program. For patients
to check the time, but do not use an alarm. When you who are fearful of exercise, supervised trials of exercise can instill
finish, sit quietly for several minutes, at first with your confidence in them and motivate them to try it.
eyes closed and later with your eyes opened. Do not Depression and anxiety are also perpetuated by negative per-
stand up for a few minutes. ceptions, beliefs, and thoughts in response to stressful situations.
6. Do not worry about whether you are successful in The successful entrepreneur who becomes depressed after a coro-
achieving a deep level of relaxation. Maintain a passive nary bypass surgery may perceive that his physical weakness is per-
attitude and permit relaxation to occur at its own pace. manent and that he will never be able to work as he did before.
When distracting thoughts occur, try to ignore them by
not dwelling upon them and return to repeating “ONE.” For him, these perceptions are facts. During patient education,
With practice, the response should come with little ef- nurses can teach such patients how to correct these inaccurate and
fort. Practice the technique once or twice daily, but not negative perceptions about recovery and their implications on fu-
within two hours after any meal, since the digestive ture functioning. Patients can be encouraged to examine their re-
processes seem to interfere with the elicitation of the flex perceptions by questions and clarifications and to challenge
Relaxation Response. the validity of their concerns. According to cognitive behavioral
therapy for depression, this intervention is called “cognitive re-
Borrowed with permission from Benson, H. (1975). The relaxation response structuring” or “realistic thinking.” It evaluates and tests the evi-
(pp. 114–115). New York: William Morrow.
dence that supports or invalidates the depressive cognitions and
assumptions. 23 Patients who are anxious about having another
heart attack can be taught that obsessive worry about their physi-
decrease depressive symptoms in cardiac patients. 137 Exercise also cal symptoms is likely to increase anxiety and physiological
seems to improve self-efficacy, decrease negative moods, 136 and arousal, which is not beneficial during recovery. Patients can be
provide social reinforcement. 138 taught relaxation strategies and methods of worry control to de-
crease anxiety. In his book for the lay public on managing anxiety
Interventions for Depression and fear, Bourne outlines several worry-control methods, such as
and Anxiety postponing worry and checking physical symptoms and schedul-
ing worry periods. 133
Chronic stress increases vulnerability to develop depression and
anxiety. These are often accompanied by negative lifestyle behav- Social Support Interventions
iors that further tax the cardiovascular system. These behaviors
may include watching excessive television, web surfing, poor diet, As educators, nurses can provide CHD patients functional support
and inadequate sleep, which increases vulnerability to more stress, in terms of education and knowledge. Anticipatory guidance about
creating a vicious cycle. 139 Treating depression and anxiety can CHD regarding the disease and the recovery process can alleviate
improve compliance with medication and heart-healthy behav- stress for both patients and families. The benefits of support and its
iors, such as exercise and better diet. 140 role as a buffer against stress can be discussed. However, patients’
Without question, depression and anxiety are associated with needs and desires for knowledge must be assessed. This is illus-
negative lifestyle behaviors: smoking, excessive drinking and eat- trated by research observations of patients with a repressive coping
ing, decreased exercise, hostile behaviors, and social withdrawal. style. Those who received a great deal of information had a higher
Patients with moderate to severe depression are likely to have mul- frequency of “heart alarms” and more medical complications. 144
tiple negative behaviors and several failed attempts to changing Patients who actively deny that they have had a heart attack are
their negative health behaviors. Such patients require psychiatric not ready to receive a lot of information. Open-ended questions
care. Patients with less severe depression often respond well to en- that allow patients to direct the flow of information should be
couragement to engage in positive activities that increase their used. A nurse can also provide emotional support by empathic lis-
connection with others, increase their sense of accomplishment, tening and encouraging social interactions. Hospital admissions
or both. Examples include initiating contact with family and for cardiac problems make most patients apprehensive and fear-
friends, sharing a meal with a friend, exercising with a friend, at- ful. Allowing patients and spouses to express these concerns can
tending a lecture, or working on a home project. Scheduling such benefit both patients and their families and provide educational
activities is a hallmark of cognitive behavioral treatment for depres- opportunities. Encouraging patients to eat with other patients,
23
sion. The rationale for this intervention is that pleasant activities facilitating their access to social visits, and having family mem-
foster connections with others or give a sense of accomplishment, bers prepare their favorite foods cook can promote connections