Importance of psychosocial status in secondary prevention and rehabilitation of coronary artery disease
Bryan P. McCormick
Indiana University, Bloomington, IN, USA
Lifestyle and behavioral factors play a major part in the development of coronary heart disease (CHD).
Rehabilitation and secondary prevention of CHD must likewise consider behavioral and lifestyle change
as adjuncts to other therapies. Principal among the psychosocial factors are depression, anxiety
and anger/hostility. Related to these negative emotions, a distressed personality style (type-D) in
which both negative emotion and social inhibition are present represents a psychosocial risk factor. In
addition, social experience, both in the resources available through social networks and the subjective
experience of isolation, is related to both the onset and course of CHD. Psychosocial interventions
have been found to be effective in rehabilitation and secondary prevention. Finally, a case is made
that all professionals working in cardiac rehabilitation and secondary prevention should be knowledgeable
in the psychological constructs of motivation and readiness for behavioral change. The widely
employed transtheoretical model of change is presented as an example of the need for interventions
to be developed that recognize patients difference in the readiness for change.
The rehabilitation and secondary prevention of
coronary heart disease (CHD) has increasingly
acknowledged the effect of psychosocial factors
in disease progression. Although psychosocial
factors have been recognized as relevant to cardiac rehabilitation
for over 30 years,1 calls for greater attention
to psychosocial status in CHD onset and rehabilitation
only began appearing in professional literature in the
mid to late 1990s.2, 3 At present knowledge of psychosocial
factors in CHD are considered core competencies
for all professionals working in cardiac rehabilitation
and secondary prevention.4 This paper reviews recent
research in psychosocial risk factors for CHD as well as
implications for rehabilitation and secondary prevention.
In addition, motivation and readiness for change
are reviewed as a critical consideration in behavioral
change as part of both rehabilitation and secondary
Psychosocial risk factors
Lifestyle and behavior represent one of the most directly
modifiable factors in secondary prevention of CHD.5
Principal among these risk factors are elevated cholesterol
and triglycerides, obesity, high blood pressure,
smoking, diabetes and sedentary behavior, and current
guidelines for secondary prevention suggest treatment in
all areas.6 Although these risk factors are appropriately
considered as biophysical factors, there is evidence that
changes in these biophysical factors may positively affect
psychosocial status. For example, even mild improvements
in physical fitness have been found to be effective
in reducing depression and subsequent mortality6 in cardiac
rehabilitation.7, 8 In addition, secondary prevention
programs targeting reductions in body mass index (BMI)
have also been shown to be effective in reducing depression,
improving social functioning and improving emotional
Depression remains as one of the most significant psychosocial
risk factors in secondary prevention and cardiac
rehabilitation. Depression is implicated in both the onset
of CHD as well as the prognosis in rehabilitation.11 Although
estimates vary, depression confers a relative risk
of onset of CHD in the range of 1.5-2.0 in initially healthy
individuals.11 Among those diagnosed with CHD, rates of
clinically significant depression has been identified in
15-20% of heart failure patients.12, 13 Depression is also
clinically significant for its role in cardiac rehabilitation.
Cardiac patients diagnosed with depression demonstrate
poorer adherence to cardiac rehabilitation regimen, and
increased odds of non-completion.14, 15 It is worth noting
that although there is not strong research evidence, preliminary
indications are that the somatic symptoms of
depression such as fatigue, sleep disturbance and appetite
disturbance have a greater effect on compliance and
completion15 as well as subsequent cardiac events.16
Anxiety has a similar role in CHD to that of depression.
First, anxiety increases the odds of the onset of CHD
events such as myocardial infarction (MI).17 Anxiety appears
to have the greatest implications in post-cardiac
event outcomes. Particularly among patients post-MI,
anxiety increases the odds of adverse events, all cause
mortality, cardiac mortality and cardiac events.18-20 There
are however studies that have failed to find such negative
outcomes.21, 22 Another area of similarity of anxiety to depression
relates to compliance with cardiac rehabilitation.
As with depression, anxiety is implicated in poor completion
rates and higher drop-out rates in rehabilitation,22, 23
but it also appears to be indicative of the likelihood of
readmission24 as well as the number of readmissions.25
Anger & Hostility
As with the other psychosocial factors, anger and hostility
are related to the development26 and earlier age of
onset of cardiac disease.27 In addition, high levels of trait
anger are associated with increased odds of recurrent
cardiac events.28 Recent research also indicates that anger
may be most relevant to negative cardiac events when
it is suppressed.29 Specifically, suppressed anger, but not
anger alone, was associated with a significantly increased
odds of cardiac death or MI. Suppressed anger was highest
among those demonstrating a type D personality. In
addition, suppressed anger has also been identified as a
contributing factor in poor sleep quality among patients
with coronary heart disease.30 Perhaps more so than
other psychosocial factors, the role of anger and hostility
among women appears to be different for men and women.
In a review of psychosocial factors in the development
of CHD in women, Low and colleagues31 identified
that hostility was less consistently associated with CHD
among women as opposed to men.
Type D Personality
Depression, anxiety and anger have all been increasingly
linked with a personality profile characterized as
type D personality. The type D personality is an extension
of early work in the psychosocial factors of CHD that were
linked to the type A personality32 which was characterized
by high degrees of time consciousness, rapidity of movement,
impatience, tenseness and overwork. In addition
to the time-pressure and impatient characteristics of the
original type A conceptualization, the type D (or distressed)
personality is seen to also include general emotional
negativity and social inhibition resulting in a general
propensity for psychological distress.33 A recent
meta-analysis on type D personality and patients with
CHD concluded that the type D personality is significantly
associated with increased major adverse cardiac outcomes.
34 The type D personality has been found to remain
as a significant predictor of adverse cardiac events after
adjusting for anxiety stress and depression.33
Social Networks and Isolation
In addition to lifestyle and emotional experience,
one’s social experiences are implicated in CHD risk. First,
social experience has been conceptualized both as an objective
factor in which social connections and social network
size are thought to be indicative of social experience.
From this perspective, small social networks (less
than 3 individuals) have been found to more than double
the odds of cardiac and all cause mortality among patients
with CHD.35 In addition, larger social networks have
been found to be associated with a decreased incidence
of major adverse cardiac events as well as improved overall
health,(36) as well as reduced left ventricular mass.37
In addition to the objective measures of social experience,
subjective approaches to social experience have
been explored principally through the examination of social
isolation and loneliness. There is evidence that higher
perceptions of loneliness are significantly increases the
risk of incident CHD; however, this association only appeared
to hold true in women.38 Finally, social isolation in
childhood has been found to be a risk factor for development
of behavioral risk factors of CHD in early adulthood.
Psychosocial status in cardiac
rehabilitation & secondary prevention
Current recommendations related to a comprehensive
approach to cardiac rehabilitation and secondary
prevention in Europe and the United States demonstrate
great similarity (Table I). Both include specific recommendations
related to management of psychosocial functioning.
Among the skills noted in both of these guides
are abilities for professionals to screen for psychological
distress including depression, anxiety, anger or hostility,
social isolation, marital/family dysfunction, sexual dysfunction
and substance abuse. In addition, it is recommended
that professionals make appropriate referrals for
psychiatric or psychological treatment as warranted by
the severity of psychological distress. Finally, comprehensive
rehabilitation or secondary prevention programs
should offer individual and group education and counseling
to address adjustment to disease, stress management
and coping strategies.
Meta analyses of the effects of psychosocial interventions
have reported significant reduction in subsequent
cardiac events and both significant and non-significant
reductions in mortality.40, 41 In addition, psychological interventions
do appear to be effective in reducing both
depression and anxiety. Psychological interventions were
also found to be most effective in reducing depression
when they included an intent to treat type-A behaviors;
however, interventions focusing on a) education about
cardiac risk factors, b) emotional support through client
discussion and c) included family members in the treatment
process were significantly less effective in affecting
Motivation & Readiness for Change
As noted previously, the management of lifestyle factors
including physical activity, weight, diet and tobacco
play a large part in cardiac rehabilitation and secondary
prevention (Table II). One of the greatest challenges in
cardiac rehabilitation and secondary prevention is that
virtually all interventions require behavioral change. As
a result, regardless of the type of approach, all interventions
should take into account patient motivation and
readiness to change.42 This should begin with an understanding
of patients’ motives for behavioral change. Cantor
and Sanderson43 asserted that goal structures are
relevant to understanding motivation for sustained behavior
in achieving goals such as behavioral change. Specifically,
people whose goals are characterized as approach
goals, in which they engage in a behavior due to
the behavior’s intrinsic value, are found to persist at the
behavior even in the face of obstacles and barriers. In
contrast, people whose goals are characterized as avoidance
goals, in which they engage in a behavior to avoid
an undesired outcome, are found to abandon such goals
much more readily in the face of obstacles or barriers.
This may be highly relevant in cardiac rehabilitation as
avoiding future cardiac events may be highly motivating
in the short term, but as an avoidance goal sustaining
motivation for behavioral change may also be much more
difficult in the long term. Thus it should not be surprising
that one of the identified psychosocial management
competencies for professionals working in cardiac rehabilitation
and secondary prevention is the knowledge and
skill to implement effective behavior change strategies
based on theoretical models of behavior change.4
One of the most widely employed models of behavioral
change is the transtheoretical model of behavioral
change.44 This model recognizes that behavior change is
a process in which individuals may be at different stages
in their readiness and ability for behavioral change. The
model presents a series of sequential stages beginning
with pre-contemplation, following to contemplation,
preparation for change, change action, maintenance of
change and includes the possibility for relapse (Table 2).
In each of these stages, individuals demonstrate different
characteristics and as a result it implies that health professionals
should use different strategies in their approach
to behavioral change.
For example, in the pre-contemplation stage, people
are unaware of the need for change. In the domain of
cardiac health and cardiovascular disease, this would be
the realm of primary prevention in which the goal would
be to make people aware of the impact of their lifestyle
and psychosocial functioning on subsequent cardiac
health and cardiovascular disease. In contrast, in the contemplation
stage, people recognize a need for behavioral
change, but still believe that changing behaviors will be
much more costly than the benefits of behavior change.
As an example, a patient may be informed that his smoking
is contributing to high blood pressure and ultimately
cardiac disease. Although he recognizes that there are
costs to his health if he continues smoking, the benefit he
perceives from smoking may outweigh the health costs
and so behavioral change is either unlikely or ineffective
at this stage. Health professionals working with clients in
this stage can support and encourage patients in identifying
both the benefits of behavioral change as well as the
coping resources necessary to initiate and sustain change.
In the preparation stage, an individual has moved one
step closer to enacting the change. At this point, although
the perceived costs may still outweigh the benefits, the
individual accepts that change is needed and prepares to
make the change. Health professionals should continue
to support patients’ internal motivation to change as well
as support the development of coping strategies and resources
to enable change. In the action stage, patients
have made the initial behavioral change (< 6 months). In
cardiac rehabilitation an initial cardiac event may be the
trigger that pushes patients from contemplation stage,
through preparation to action. As noted previously however;
this motivation for action may be due to a desire to
avoid a negative outcome, such as another cardiac event.
The challenge for health professionals working with patients
at this stage is to find ways to internalize motivation
for the new behavior and integrate it into their lifestyle.
This internalization and adoption of the new behavior is
characteristic of the maintenance stage of the transtheoretical
model. Finally, the model recognizes that relapse
and return to old behaviors is a possibility. Particularly in
the area of cardiac rehabilitation and secondary prevention,
significant lifestyle changes are needed. The challenges
of initiating and maintaining such changes will
have broad impacts to both the patient as well as his or
her social environment. Health professionals working in
this area should recognize that relapse is not necessarily
an indication of failure, but instead an indicator of the
difficulty of the change for the patient. Patients may have
to work through the stages of change multiple times before
new behaviors become a part of their way of life and
health professionals must adapt their interventions to
the appropriate stage of patients’ readiness for
Psychosocial factors play a significant role in both the
onset and course of CHD. Among the most widely recognized
factors are depression, anxiety and anger/hostility.
Each of these is implicated in initial disease progress as
well as prognosis for rehabilitation and subsequent
health. In addition, social isolation, although not as well
articulated as the above factors, is implicated in disease
progress and rehabilitation. There is reason to believe
that social isolation is interrelated with other psychosocial
factors. As well, although lifestyle interventions typically
target improvements in biophysical functioning,
they also have the ability to affect psychosocial factors.
Finally, efforts to engage patients in behavioral change
must be grounded in an understanding of patient motivation
and readiness for change. Such knowledge and skills
will enable professionals to develop therapeutic regimen
that work with patients to mobilize their resources to enact
and sustain behavioral change.
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