Work

Psychological Knowledge as an Essential Component of Adequate Medical Care: Position Statement for the Integration of Biopsychosocial Components in Modern Cardiology

Year: 2025

Type: article

Abstract: The knowledge of heart mechanics was first described in 1628 by Harvey.[1] Scientific understanding of the heart’s function and its diseases developed rapidly from the 19th century to today’s high-tech medicine. However, it was not until the end of the last century that it was rediscovered that the human being should be seen as a whole. Connections between the physical and the psychological side, between the heart and feelings, received attention. Somatic concerns and mental health are not isolated domains but deeply interconnected, influencing each other. Cardiovascular diseases (CVDs) can lead to mental health issues such as stress, anxiety, and depression. Conversely, mental health issues are associated with increased cardiac risk. For example, the association between depression and coronary heart disease has been demonstrated in numerous studies.[2] There are multiple pathways by which psychological factors influence CVD risk. These include physiological pathways (such as inflammatory response, glucose and lipid homeostasis, and coagulation) as well as indirect effects through health behaviors that influence CVD.[3] Accordingly, the importance of psychosocial factors can now be found in many treatment guidelines in cardiology.[4] However, the integration of psychological aspects into cardiological care has remained largely under-represented. Therefore, the necessity of implementing a holistic approach to health care that integrates the treatment of physical symptoms of CVDs with interventions aimed at addressing mental health needs to be emphasized. For the treatment and day-to-day care of patients and in all areas of prevention, it is essential to know the interrelationships between heart disease, psychology, and the social environment and to take them into account in treatment. Extensive research is now available on a holistic perspective referred to as the biopsychosocial model. The preponderance of data suggests that interventions to improve psychological health can have a beneficial impact on cardiovascular health.[5] INTERACTION OF SOMATIC AND PSYCHOLOGICAL FACTORS IN CARDIAC DISEASES Evidence for the interactions between cardiac diseases and mental health is manifold. Mental health problems such as anxiety and depression are associated with a significant increase in the risk of cardiac diseases and predict the course of the disease. For example, depression is linked to a two-fold increase in the risk of a heart attack, and even mild depressive symptoms are associated with higher cardiac recurrence risk and medium-term mortality risk among patients with known heart disease.[6] Furthermore, medication nonadherence in cardiac patients was associated with depression.[7] The higher cardiological risks in depressive patients are, among other factors, due to a lack of motivation for a lifestyle change in depressive patients.[2] Another psychological risk factor is psychosocial stress, which is associated with numerous CVD presentations, while acute stress can provoke cardiac events, and even the routine stress experienced throughout the day can provoke myocardial ischemia and cardiac arrhythmia in patients with heart disease.[8] Stress triggers hemodynamic, vascular, and immune perturbations.[9] Unrecognized mental health issues may further amplify the perceived stressfulness of cardiac disease, leading to a vicious cycle of psychological distress and adverse cardiovascular outcomes.[8] In the first decade of the 21st century, high-quality research demonstrating objective benefits (mortality/events, reduced healthcare costs, and reduced rates of hospital admissions) was still relatively scarce.[3] Over the last 20 years, several quality studies provide evidence for the beneficial effects of mental health treatment for anxiety or depression in patients with CVD. These studies include objective parameters such as reduced hospitalizations, emergency department visits, and in some conditions improved survival.[10] Furthermore, there is robust evidence that implementing routine psychological assessment is associated with psychological health.[11] A recent review and meta-analysis of randomized controlled trials (RCTs) among patients with coronary artery disease provides evidence that cognitive behavioral therapy (CBT) is effective in reducing depression symptoms, especially in the 1–3 months postintervention, with promising results for longer follow-up (6-month postintervention).[12] A 2020 Cochrane review and meta-analysis of RCTs investigating the effects of CBT and other varied behavioral interventions among patients with ischemic heart disease, showed that psychological interventions were associated with a 21% lower risk of cardiovascular mortality across 12 years.[13] Despite these advances in research, prevention-focused interventions that address mental health and potentially decrease cardiovascular risk are rarely included in prevention and disease management programs. Furthermore, despite treatment guidelines that include attention to a patient’s psychological health, psychological assessment, and related treatment, remain insufficiently recognized in the clinical care of patients with heart disease. In general, mental health risks are under-recognized in cardiology clinic settings. According to recent studies, about 60% of cardiological patients suffer from anxiety. Up to 50% of cardiology patients present with significant depressive symptoms, and a large number even show symptoms of post-traumatic stress disorder (PTSD).[5] Nevertheless, standard screenings of cardiological patients do not include these mental health issues. Even where clinical guidelines recommend this focus, it falls upon the physician to do the work. This is a big problem because (1) the physician does not have the time and (2) they are not trained to do this, for example, an integrated, team-based care approach is needed where a person with expertise, and certification is responsible for this part of patient care. A PATH FORWARD: INTEGRATED CARDIOVASCULAR CARE As we have stated, the importance of psychological and psychosocial factors, as both contributors to incident CVD risk and drivers of chronic CVD outcomes, has been recognized. Position statements and white papers from the leading professional groups have called for attention to “psychological health” in the care of patients, including the European Society of Cardiology, American Heart Associations, and the American College of Cardiology. The American Heart Association includes four behavioral factors in its “Life’s Essential 8” paradigm.[3] The other four factors are biomedical but require a degree of patient participation and adherence to address, which also places them in the psychological domain. The clinical health psychologist, because of their specialized training that includes a focus on various medical diseases – for example, CVD and its medical risk factors and comorbidities, chronic pain – can interact with both patients and providers more effectively, bringing an understanding of the medical problem and the bidirectional nature of psychological health with the medical health problem.[14] Yet, while calling for this type of patient care for patients at risk for and with known CVD, no pathway is provided to accomplish this. The best approach offered by these papers is for the treating physician to address these issues with patients and/or to refer patients to outside specialty providers, which leads to fractured care. Yet, models are available from other areas of health sciences. The development and testing of integrated care models in the primary care context offer a compelling model for testing in the delivery of cardiovascular care. This integrated care approach was pioneered within the US Veterans Healthcare Administration, a system of care offered to military Veterans. Care is team based, according to the presenting needs of the patient. For example, a clinical health psychologist is involved in the team care of a patient with hypertension and elevated lipids who is having difficulty adhering to a healthy lifestyle and prescribed medication. The psychologist works with the patient but also with other team members (e.g., physician, nurse, dietician, and pharmacist), teaching them the most effective communication strategies to support the patient in making the needed choices for optimal health. Because of their training, the clinical psychologist is also quickly able to ascertain whether other factors – for example, depression and PTSD – are playing some role in nonadherence, inform the team, and address the issues with the patient. The results in the primary care setting are reduced utilization, increased patient satisfaction, and better health outcomes. A similar approach is seen in the Collaborative Care Model, which was developed to address depression in primary care patients and has been extended in research trials to patients with chronic coronary disease, postcoronary bypass surgery, and heart failure. An ongoing pragmatic trial across several EU countries is testing this approach for patients with heart failure, distress, and multimedical morbidity.[15] Ideally, this model would be applied to the cardiovascular “space” as well. Indeed, given the nature of CVD in its many forms, it could be considered essential that the “mental health provider” within an integrated cardiovascular care model be a clinical health psychologist with additional specialized training in this area.[14] To ensure clinical relevance, the development and testing of integrated cardiovascular care models will need to utilize a pragmatic clinical trial framework with implementation strategies embedded from the outset. Furthermore, because these models rely upon allied healthcare providers working together to care for the patient as a whole person rather than a collection of elements (biomedical, psychological, behavioral, and situational), they must also include the development and testing of new models of training, most specifically training in how to work as a team of individuals with unique expertise that can be complementary, with proper training in doing so. We call for and look forward to this development and testing. CONCLUSION The successful application of scientific medicine to cardiology care requires the consideration of psychological aspects. First, this implies that psychosomatic complaints cannot be dismissed as imaginary problems. Patients suffer from them and expect their issues to be taken seriously and not dismissed. Medical doctors (MDs) need to be aware that psychosomatic complaints have a massive impact on the course of diseases, particularly cardiological diseases, potentially leading to an increased risk of mortality. The long-term prognosis, for example, in the case of CVDs, as well as the well-being and quality of life of the affected persons, depends less on invasive procedures than on holistic preventive care, in the sense of a “multimodal intervention.” It should go without saying that clients are taken seriously and treated with respect; this promotes their private acceptance of measures (e.g., taking medication) and, as a result, their participation in general. MDs increasingly recognize the importance of psychological comorbidities, as they have recognized the importance of lifestyle and adherence to cardiac prevention and prognosis. Yet, they do not have the time, are not prepared – and arguably, not qualified – to address these issues. Research has shown that well-being can be achieved despite suboptimal physical and/or mental health. Patients with a severe chronic illness often report better quality of life and well-being than people with less serious diseases.[4] Clearly, a new approach to patient care, for both prevention and management of CVD, is needed. This broadened perspective requires the integration of these factors in the training of MDs, ideally side-by-side with the training of their psychosomatic/health psychology counterparts so that when they become MDs, they have more knowledge about the psychological and social side of illnesses, consider these in patient care, and work within interdisciplinary or integrated care teams, as already used in primary care. Author contributions Jürgen Beckmann wrote the first draft of the manuscript with Matthew M. Burg. Annika Freiberger. Allison E. Gaffey, Caroline Andonian-Dierks, Denise Beckmann-Waldenmayer, and Julia Lemmer added sections based on their personal expertise. All authors participated in the revisions of the manuscript and manuscript editing. All authors have given final approval for the current version to be published. Ethical statement Ethical statement is not applicable for this article. Declaration of patient consent Patient consent is not applicable for this article. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest Dr. Jürgen Beckmann is an Editorial Board Member of Heart and Mind. The article was subject to the journal’s standard procedures, with peer review handled independently of Dr. Jürgen Beckmann and the research groups. There are no conflicts of interest.

Source: Heart and Mind

DOI: 10.4103/hm.hm-d-24-00144