The heart-mind connection

Behavioral health and employee assistance professionals have an important role in preventing and managing heart disease, which is a leading cause of death and disability in the United States. As with other diseases, heart disease often is associated with other disorders. Of particular note is the association between heart disease and behavioral health conditions.

Cardiovascular and Mental Health

Depression develops in one in four individuals who have a heart attack. When depression and heart disease are present together, the risk of death is three-and-a-half times greater than in nondepressed patients.1

Many studies have provided evidence of a link between heart disease and depression, anxiety, hopelessness, pessimism, hostility, and anger.2–4 Depression and anxiety are suspected to directly affect heart rhythms, increase blood pressure, alter blood-clotting capabilities, and lead to elevated insulin and cholesterol levels.5 Studies also have shown that the risk of having a heart attack doubles for two hours after an angry episode.6

Assessment and Treatment Planning

Given the prevalence of heart disease and the increased risk that develops when comorbid mental health disorders are present, behavioral health practitioners and employee assistance professionals should continually educate themselves about the risk factors and protective measures that may be addressed in a therapeutic behavioral health setting.

The primary risk factors for the development of heart disease are well known: smoking, a sedentary lifestyle, hypertension, high blood cholesterol levels, obesity, diabetes, and a family history of heart disease. Yet an effective disease management program or clinical intervention must address the connection between emotion, behavior, coping strategies, and cardiovascular health in a holistic, integrated manner. Addressing risk factors in a comprehensive treatment plan with a client and collaborating with treating medical professionals are imperative.

Behavioral health clinicians are in a unique position to help their clients identify their risk factors, encourage them to follow up with their medical practitioners, and address any distress they may be experiencing. With their focus on helping employers address employee health and productivity, employee assistance professionals cannot ignore the fact that coronary heart disease is a leading cause of premature, permanent disability in the U.S. workforce.7 They are in a unique position to raise awareness within their client organizations, provide thorough assessments and referrals for employees and their family members, assist employees returning to work, and provide follow-up services.

Collaboration and Referral

Behavioral health practitioners working in the community mental health setting are well-positioned to improve community awareness about the connection between heart disease and behavioral health disorders, and to help individuals receive appropriate diagnosis and treatment. This also is true for employee assistance professionals, who can effect similar change by leveraging the workplace as a forum for organizational and individual change. Here are some suggestions:

• Identify community resources where clients with heart disease risk factors can be referred for medical assessment (especially important for clients without insurance).

• Train staff to recognize heart disease risk factors, and to refer patients to appropriate resources.

• Develop relationships with area agencies/providers who treat those with (or who provide education about) heart disease. Work to raise awareness among these agencies of the connection between heart disease and behavioral health issues, and ensure that they know where to refer clients for behavioral health assessments.

• Encourage providers who treat clients with heart disease to refer to behavioral health providers those who need support in making lifestyle changes to improve their heart health.

• With employer clients, develop a communication strategy to reach an entire employee population with educational messages and reminders of available services and resources.

Supporting Clients

With a heightened sensitivity to heart disease's risk factors and protective measures, behavioral health and employee assistance professionals are positioned to recommend and deliver behavioral interventions to their clients who have (or are at increased risk for) heart disease. Specifically, they can:

• assess willingness to seek treatment;

• develop interventions to “meet the patient where he/she currently is”;

• talk about the heart-mind connection;

• screen for comorbid behavioral health conditions;

• encourage self-screening for those who are reticent to seek psychological screenings;

• coordinate care between physical and behavioral health providers;

• encourage lifestyle modifications that reduce stress and anxiety; and

• encourage clients to join support groups.

If a client recently has been diagnosed with heart disease, the clinician can:

• suggest that he/she learn as much as possible about the disease and get a referral to a cardiac rehabilitation program;

• coach him/her to set reachable recovery goals, expect setbacks, and celebrate successes;

• encourage the client to talk about his/her feelings, avoid isolation, and watch for signs of depression, as he/she copes with the emotions surrounding a diagnosis; and

• monitor how the individual's lifestyle changes are positively or negatively affecting his/her work performance.

To manage heart disease in the long term, clients (with the help of their behavioral health or employee assistance clinician) should strive to:

• become optimists;

• change “risky” behaviors (such as smoking or inactivity);

• manage stress, anger, and depression;

• reclaim their sex life and physical intimacy;

• believe in something greater than themselves;

• return to work; and

• form a recovery team that will provide support and watch for signs that the patient may not be coping well.

Quitting smoking, maintaining a healthy diet, and following an exercise regimen are recommended ways to decrease heart disease risk. For most people, however, these changes don't occur overnight. The “Stages of Change” model recognizes that for many, behavior change is a gradual process:

• Precontemplation—unaware of the need or unwilling to change

• Contemplation—aware of the need for change and considering it

• Preparation—preparing to change

• Action—actively working to change behavior

• Maintenance—trying to maintain the new behavior without reverting to the old one; relapses are common and become part of the process of working toward established change

Behavioral health and employee assistance clinicians can support their clients in changing behavior by helping them at each of these stages—from providing accurate information to those in the precontemplation stage, to providing support, encouragement, and tools to those in the maintenance stage.

Opportunities

Behavioral health provider organizations that actively address the connection between heart health and mental health will find themselves in a better business position, as well. By treating the behavioral contributors to heart disease and helping clients to make lasting healthy lifestyle changes, behavioral health and employee assistance professionals will encourage greater compliance with treatment regimens, decrease the chance for other medical conditions, and aid employees in returning to work in a more timely fashion. Through their contributions to improved health outcomes and decreased medical and disability costs, behavioral health professionals will strengthen their relationships with employer groups, health plans, insurers, and healthcare providers.

Summary

A clear connection exists between mental health and heart disease, which requires assessment, collaboration with other professionals, and behavioral health interventions. Psychosocial factors such as stress, anger, anxiety, and depression promote heart disease. Alternately, the use of mood-enhancing or stress-reducing techniques—such as optimism, meditation, counseling, exercise, and imagery—as well as a lifestyle behavioral change approach can have a positive effect on reducing the incidence of heart disease. Behavioral health treatment can improve medical conditions and quality of life.

References

1. Duenwald M. More Americans seeking help for depression. New York Times. June 18, 2003: A1, A22.
2. Williams RB. Neurobiology, cellular and molecular biology, and psychosomatic medicine. Psychosom Med 1994; 56:308-15.
3. Denollet J, Brutsaert DL. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation 1998; 97:167-73.
4. Kubzansky LD, Davidson KW, Rozanski A. The clinical impact of negative psychological states: Expanding the spectrum of risk for coronary artery disease. Psychosom Med 2005; 67 (suppl 1): S10-S14.
5. National Institute of Mental Health. Depression and Heart Disease. Bethesda, Md.: National Institute of Mental Health; 2002: 1. Available at: https://www.nimh.nih.gov/publicat/NIMHdepheart.pdf.
6. Sotile WM. Thriving With Heart Disease: A Unique Program for You and Your Family/Live Happier, Healthier, Longer. New York:Free Press; 2003:139.
7. Addressing the Nation's Leading Killers. Centers for Disease Control and Prevention; 2006: 2. Available: https://www.cdc.gov/nccdphp/publications/aag/pdf/aag_cvh2006.pdf.