Psychosocial Risk Factors and Behavioral
Interventions in Cardiovascular Disease
Nathan D. Wong, PhD, FACC, FAHA
Professor and Director
Heart Disease Prevention Program
Division of Cardiology, University of California, Irvine, CA
USA
President, American Society for Preventive Cardiology
“ For every affection of the mind that is
attended with either pain or pleasure, hope
or fear, is the cause of an agitation whose
influence extends to the heart, and there
induces change from the natural
constitution,in the temperature, the pulse
and the rest”
- Dr William Harvey, 1962
The term
“Psychosocial”
broadly categorizes
factors which are:
• Psychologic – e.g, anxiety, depression
• Psychosocial – e.g., work stress,
discrimination, emotional support
• Social-structural – e.g., socioeconomic
status, social integration, neighborhood
effects
Source: Rozanski A, Chap 34, Preventive Cardiology, Blumenthal, Foody, Wong, eds.
Proposed Mechanisms Relating Chronic
Stress to Atherosclerosis
Rozanski et al., JACC 2005
Six Reasons that Promote Interest in
Evaluation and Management of
Psychosocial Stress in Heart Disease
Rozanski et al., JACC 2005
INTERHEART Study: Psychosocial
Index and Risk of Acute MI
Psychosocial index based on individual items of depression, locus of control, work
or home stress, financial stress, and adverse life events. Yusuf, Lancet 2004
Depression
• Estimated prevalence of major depression in the US is
14%, but up to 30% in cardiac patients
• Characterized by a depressed mood and combination of
other symptoms such as weight change, sleep
disturbance, insomnia, fatigue, feelings of guilt,
worthlessness, and/or hopelessness.
• Depression can stimulate the autonomic
nervous system and HPA axis. It is also
proinflammatory and is associated with
increases in CRP, fibrinogen, IL-6 and other
inflammatory measures, independent of BMI
and other risk factors.
• Of all psychosocial factors, evidence of association with
CVD is strongest for depression.
Depression: Evaluation
• Measurement can be done by:
– Beck Depression Invetory
– Center for Epidemiologic Studies Depression Scale (CES-D)
– Diagnostic and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV)
Major depression according to DSM-IV criteria indicates the
presence of severely depressed mood and/or inability to take
pleasure in all or most things that were previously considered
enjoyable, lasting 2 weeks or longer and accompanied by
functional impairment and somatic complaints, such as fatigue or
loss of energy nearly every day, insomnia or hypersomnia,
change in appetite, diminished ability to concentrate, feelings or
worthlessness or inappropriate guilt, and recurrent thoughts of
death or suicidal ideation
Depression and CVD (cont)
• Frasure-Smith et al (JAMA 1993) reported
a 4-fold increase in mortality during 6
months following acute MI from
depression in cardiac patients.
• Meta-analysis examining depression as a
factor in development of CHD in healthy
individuals showed a risk factor-adjusted
RR=2.69 for CHD incidence ( Rugulies,
Am J Prev Med 2002).
Depressive Symptoms and Cardiac
Free Survival in Post-MI Patients
Lesperance et al. Circulation 2002
Depression and CHD
Depression and Brachial FMD
Anxiety and CHD
• Anxiety is characterized by heightened levels
of perceived fear and nervousness– may
include panic disorder, social phobia,
obsessive-compulsive disorder, acute
stress disorder, posttraumatic stress disorder.
• Clear relation to sudden cardiac death in a dosedependent fashion
• 32-year follow-up of men in the Normative Aging Study
who reported two or more phobic anxiety symptoms had a
3.2-fold increased risk of fatal CHD and 5.7-fold increased
risk of sudden death.
• Ventricular arrhythmia may be the underlying mechanism
since no relation seen between anxiety and MI. Anxious
individuals also have reduced heart rate variability.
• Some population surveys show prevalence to be
approximately 20%
Post Traumatic Stress Disorder
(PTSD)
• Present if after exposure of an inciting traumatic event the
subject report re-experiencing the event, hyperarousal,
and avoidance of traumatic reminders and emotional
numbing.
• A retrospective study of men who have served in the
military shows a stepwise relation between symptoms of
PTSD and nonfatal MI and cardiac death (Kubzansky,
Gen Psychiat 2007).
• Study of 1059 women shows relation between PTSD and
incident CHD (Kubzansky, Health Psychol 2009).
• Boscarino evaluated 4328 men who served in Vietnam
war; PTSD associated with more than a two-fold
increased risk of subsequent cardiac mortality,
independent of depression symptoms (Psychosom Med
2008).
Source: Rozanski A, Chap 34, Preventive Cardiology, Blumenthal, Foody, Wong, eds.
Pessimism and Optimism
• Optimists tend to see negative events
as temporary and positive events are
more permanent; negative events
are attributed to external causes rather
than self-condemnation.
• Pessimists have an opposite
explanatory style to events.
• One study of 7216 subjects showed the
extent of pessimism to be directly related to the risk of
all-cause mortality (Grodbardt, Psychosom Med 2009)
• In the largest such study, the Women’s Health Initiative
showed among 97,253 women that those those who
were optimistic had a 30% lower rate of cardiac
mortality (Tindle, Circulation 2009)
Pessimism vs. Optimism and Cardiac Events
Personality Constructs: Type A
Behavior Pattern
• The Type A behavior pattern includes a harddriving, time-patient, and hostile behavior.
• Friedman and Rosenman showed the Type A
Behavior Pattern to be related to both CAD risk
and recurrent MI; however subsequent studies
showed no relationship, so this has been of
diminished interest.
• The Recurrent Coronary Prevention Project did
show intervention from counselling on Type A
behavior to reduce recurrent MI rates and
cardiac deaths (Friedman et al., Am Heart J
1986)
Hostility
• Reflects emotional (anger, contempt),
behavioral (verbal and physical
aggression), and cognitive (cynicism, mistrust)
factors.
• Predicts incident CHD in healthy individuals, even after risk
factor adjustment (Niaura et al.. Health Psychol 2002).
• Hostility is associated with heightened cardiovascular
reactivity and higher blood pressure.
• Higher prevalence in those with lower SES; has been
suggested as a mechanism linking low SES with CVD
outcomes.
• May be a stronger indicator of incident CHD than of
recurrent CHD or its progression.
Social Relations
• Vast literature on social networks,
social support, and CVD
• Alameda County Study showed those who lacked
ties to others (index of contacts with friends and
relative, marital status, and church membership)
were 1.9-3.1 times more likely to die over 9 years,
including from ischemic heart disease and other
causes.
• A large study in Tecumseh, Michigan found a
strong positive association in men, but not women
between social support and mortality,. Even after
adjustment for other risk factors.
• US Physicians Study showed socially isolated men
had a 1.8-fold significantly greater risk of fatal CHD
in multivariable analysis/.
Social Support and Mortality
Marriage Satisfaction and Carotid
Plaque Presence and Progression
Positive Emotions and Well-Being
• Recent research has focused on positive psychological
factors.
• Positive emotions have been defined to include
happiness and states of being that reflect a positive
engagement with the environment such as curiosity and
interest.
• This gives the individual increased ability to cope with
stress.
• Metaanalyses involving 70 studies shows positive wellbeing to be associated with lower mortality (Chida,
Psychosom Med 2008).
• A study of 1238 elderly persons showed those who
identified with a higher purpose in life had a 40% lower
risk of mortality over 2.7 years (Boyle, Psychosom Med
2009).
Laughter, Mental Stress and effects on
Brachial Reactivity
Purpose in Life and Mortality
Low Purpose
Job Strain and CHD
• Falk et al (Am J Pub Health 1992)
showed job strain to be associated
with a 2-fold increase in mortality; this
was amplified when accompanied
with poor social networks.
• Other studies have shown a higher
prevalence of MI in those with
increased job strain, and higher job
control to be associated with a lower
prevalence of hypertension.
• Some studies have shown no relation
of job demands or strain with
hypertension or elevated blood
pressure.
Effort-Reward Imbalance (ERI)
• This construct argues that risk is increased
when workplace effort is not
commensurate with tangible—eg salary or
intangible—support rewards.
• Prospective studies show ERI predicts
CVD incidence, even after adjustment for
other risk factors.
Conceptual Models of Work Stress
Effects of Psychosocial Intervention
• General effects of psychosocial interventions have been
modest.
• A metaanalysis of 36 studies involving 12,851 patients
showed only a slight reduction in non-fatal MI and no
reduction in cardiac mortality; however, many studies
often had a negligible improvement in anxiety or
depression (Ross, Cochane Database Syst Rev 2009).
• However, in the cardiac rehab setting, a metaanalysis of
23 randomized trials showed all-cause mortality to be
28% lower in those trials that included psychosocial
interventions compared to those who did not (Linden,
Eur Heart J 2007), but reduction in mortality seen only in
those who effectively reduced psychological distress.
From Rozanski A, Chap. 34 Preventive Cardiology, Blumenthal, Foody, Wong, eds.
Intervening on Depression:
ENRICHD Trial (Berkman LF et al., JAMA 2003)
• Enhancing Recovery in Coronary Heart Disease
(ENRICHD) study was a multicenter randomized
clinical trial of 2,481 post-MI patients
• Subjects met criteria DSM-IV criteria for major
depression, minor depression with hx of major
depression, or met certain criteria on a social
support instrument.
• Primary endpoint of cardiovascular mortality and
non-fatal recurrent MI
• Intervention involved 6 group sessions of cognitive
behavioral therapy over 6 months, followed by
open group membership, with SSRI use also
allowed for unremitting or severe depression in
both groups.
ENRICHD (cont.)
• Intervention did not increase event-free survival after 29
months (75.8% vs/ 75.9%). Also no differences in
mortality or infarction in any of the subgroups (e.g. those
isolated and depressed).
• There were, however, significant improvements in
depression and social support effected by the
intervention.
• Lack of overall benefit may be due to improvements in
depression and social support that also occurred in the
usual care group, as well as high SSRI use in both
groups.
• A follow-up analysis showed that those who responded
with a reduction in depression had a reduction in late
mortality.
Intervention Trials on Stress
• Based on the Ischemic Heart Disease Life
Stress Monitoring Program, involving 461
male pts recovering from MI randomized to a
stress monitoring intervention vs. usual care.
Intervention involved home nursing
interventions, individually tailored involving
education, support, collaborative problem
solving, and referral.
• After 1 year, risk of death due to cardiac
causes was reduced in half, and after 7
years differences still persisted (Fraser-Smith
et al, Psychosom Med 1985 and 1989).
Intervention Trials (cont.)
• Montreal Heart Attack Readjustment Trial
involved treatment of life stress in a larger cohort
of 1376 men and women post-MI, but showed
no benefit, and in fact a significant increase in
cardiac and all-cause mortality among women in
the intervention group (Fraser-Smith et al., The
Lancet 1997).
• Those responding to the support intervention
within two home visits had improved outcomes,
compared to those who continued to display
high levels of distress.
Rozanski et al., ACC Review on Psychosocial Factors and
CHD, JACC 2005
Stepped Collaborative Approach
for Managing Psychosocial Stress
Rozanski et al., JACC 2005
Screening for Psychosocial Risk:
AHA Science Advisory on Depression
(Lichtman J et al. Circulation 2008)
• The recommendations, which are endorsed by
the American Psychiatric Association, include:
– early and repeated screening for depression
in heart patients
– the use of two questions to screen patients –
if depression is suspected the remaining
questions are asked (9 questions total)
– coordinated follow-up for both heart disease
and depressive symptoms in patients who
have both.
From: Lichtman J et al., Circulation 2008
Lichtman J et al., Circulation 2008
AHA Science Advisory on Depression:
Other Recommendations
• Evaluation by a professional qualified in diagnosing and
managing depression
• Screening for other psychiatric disorders.
• Treatments include cognitive behavioral therapy, physical
activity, cardiac rehabilitation, and/or antidepressant drugs.
• Selective serotonin reupake inhibitor (SSRI) treatment may be
effective for treating depression. Studies show mixed findings
in relation to cardiac events and mortality.
• Routine screening should be done in multiple settings, including
the hospital, physician’s office, clinic and cardiac rehabilitation
center to avoid missing the opportunity to effectively treat
depression.
• Coordination of care between health providers is essential for
patients with combined medical and psychiatric diagnoses.
Lichtman J et al., Circulation 2008
From Rozanski A, Chap. 34 Preventive Cardiology, Blumenthal, Foody, Wong, eds.
Steps to Promote Effective Adherence to
Behavioral Suggestions (cont.)
From Rozanski A, Chap. 34 Preventive Cardiology, Blumenthal, Foody, Wong, eds.
Summary
• Evidence of associations between a number of
psychosocial factors--including depression,
anxiety, hostility, social networks and support,
and occupational stress with cardiovascular
disease.
• Adverse psychosocial characteristics to cluster
with traditional biological and behavioral risk
factors
• The highest levels of psychosocial risk are
generally found among the socially
disadvantaged.
From Bennett and Berkman, Preventive Cardiology 2005
Summary (cont.)
• Results of large-scale clinical trials of
psychosocial interventions have been mixed
with respect to their impact on CVD outcomes.
• Screening of certain psychosocial factors,
especially depression, is recommended in the
primary and secondary prevention setting.
• Greater consideration of psychosocial influences
on cardiovascular outcomes and behavioral risk
factors may enhance clinical efforts to improve
both primary and secondary prevention
outcomes.