Editorial
(Mayo Clinic Proceedings. 1996; 71:817-819)
(Accompanying my lead article on pages 729-734)
Identification and Treatment of Psychosocial
Risk Factors for Coronary Artery Disease |
the article adds yet one more piece of evidence that psychosocial
factors have a major role in destabilizing coronary artery disease and
leading to new coroney events in some fashion. The article is also valuable
in that it is only the second published study of psychosocial risk factors
to assess PTCA-treated patients, an increasingly large group of patients
with a high risk of recurrence of coronary artery disease that is potentially
available for future prospective studies. |
prevention. Low socioeconomic status may create further direct problems
with receiving proper medical care. |
Furthermore, use of the Structured Interview in the routine clinical
setting has some limitations-specialized training is needed, and the
interview and scoring necessitate more time and expertise than self-report
questionnaires such as the SCL-90-R. |
the total group, 862 patients were randomized to either a “cardiac
counseling” group (N=270) or a “type A counseling”
group (N=592). The other 151 patients, who did not volunteer for randomization,
received usual care. The 4.5-year recurrence rates were 12.9% for
patients in type A counseling in comparison with 21.2% for those in
cardiac counseling and 28.2% for those receiving usual care. |
An additional 16 intervention trials involving smaller numbers of
patients with coronary artery disease have measured either mortality
or recurrent events. These results have recently been reported in a
meta-analysis by Linden and associates.[15] Interventions have included
such varied techniques as group psychotherapy, stress management training,
music therapy, and relaxation training. Linden and colleagues calculated
a statistically significant odds ratio (control/treatment) of 1.84 for
2-year morbidity and 1.70 for 2-year mortality for all fully randomized,
controlled trials. |
Recommendations – In this brief discussion of the topic of psychosocial risk factors in coronary patients, especially those who have had myocardial infarction, recommendations for current practice should be addressed. Clearly, the theory that psychosocial risk factors constitute a tangible problem for coronary patients has been well established in the literature. Although many potential types of evaluation of psychosocial risk are available, a self-report inventory is probably sufficient to identify a subgroup at high risk. Various types of self-report inventories are available, including the SCL-90-R that is used in psychosocial screening procedures at Mayo. Screening should probably be done as early as possible after the acute event, either just before dismissal or early in the outpatient rehabilitation program, inasmuch as our own and other studies have shown that the divergence in recurrent events between distressed and nondistressed patients begins almost immediately after dismissal from the index hospitalization. The data on intervention do not currently favor one strategy over another. In fact, they are instead suggestive of a “Hawthorne effect,” in that any sincere attempt at reducing distress in these high-risk patients seems to result in a favorable influence on their recurrent event rates. Thus, the intervention used in a particular clinical setting may, at least for the present, best be determined by available resources. Small rehabilitation programs may be limited to individualized treatment-referral to psychiatry, psychology, or social work assistance or perhaps just extra attention and care from nursing, if that is the only resource readily available. |
Larger programs may be able to use groups to reduce the cost and resource utilization for dealing with psychosocial risk factors. In areas where cardiac rehabilitation programs do not exist or in cases in which patients are unable or unwilling to participate, individual physicians will have to assume responsibility for screening and intervention for this important component of secondary prevention. Just as cigarette smoking and hyperlipidemia must be addressed in the coronary patient, likewise depression and other manifestations of heightened distress should be evaluated and treated. Whether selective serotonin reuptake inhibitors will become the “magic potion” for treating psychosocial risk in coronary disease, as hydroxylmethyl-glutaryl-coenzyme A reductase inhibitors have become for treating hyperlipidemia, remains to be demonstrated. Until such data are available, we can at least rely on conventional group and individual therapy for these patients. Thomas G. Allison, Ph.D., M.P.H.
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2. Williams RB, Barefoot JC, Califf RM, Haney TL, Saunders WB, Pryor
DB, et al. Prognostic importance of social and economic resources among
medically treated patients with angiographically documented coronary
artery disease. JAMA 1992; 267:520-524 |
10. Frasure-Smith N, Lesperance F, Talajic M. Depression following
myocardial infarction: impact on 6-month survival. JAMA 1993; 270:1819-1825 |