Mental health treatment to assist in heart disease improved outcomes

Mental health and heart disease progression

The concept of stressed patients suffering higher rates of mortality following a major cardiac event is not entirely new. The healthcare system’s solution to address the link between these two high-risk categories is to prescribe an increasing repertoire of drugs to treat symptoms. In cases of depression and heart disease dual diagnoses, high rates of antidepressants are prescribed, along with separate regimens of care to manage the physical heart aspects (Yekehtaz et al., 2013). The unaddressed consideration in this form of treatment is the high cortisol levels that alter key metabolic pathways, which exacerbate current heart disease etiologies. At the root cause of heart disease is the degradation of both heart and systemic blood vessels. Chronic stress via poor mental health overdrives both catecholamines and cortisol (Scheer et al., 2019), upregulating pro inflammatory and cellular death pathways in the key endothelial lining of these vessels (Eswarappa et al., 2019). Following disruption of the intact endothelial lining of vessels, primarily due to inflammation, plaque deposition ensues closing vessels (Eswarappa et al., 2019). The rate of plaque accumulation has detailed subsets of reactions, centering on lipid levels and the body’s inflammatory response (Dimsdale, 2008; Henry, 1986).

Inside the heart is a similar, related story in terms of progression, in that stress conditions alter cardiac function through energy utilization pathways (Nørstrud et al., 2019). Most recently, studies support that chronic stress alters cardiac metabolism, leading to burnout in the switch from normal fatty acid metabolism to glucose (Depre et al., 1999). This critical switch then leads to cellular death after mitochondria within cells essentially accrue excess reactive oxygen species, which do not clear and lead to myocyte death. The net death rate in these patients in effect increases at higher rates (Doenst et al., 2013). Therefore, improvements to mental health and chronic stress may have a measurable impact on actual pump performance and baseline arterial anatomical health.

Anti-depressants and improved heart functions

A provocative translational science article most recently published (Schumacher et al., 2015) by a top therapeutics’ research and development laboratory found that paroxetine, the most prescribed SSRI for depression, has side effects in boosting heart function via upregulating a known protein that is both cardio protective and improves pump function. As such, it was established that this SSRI had a positive influence in the heart, in addition to its known effects in the brain (Thal et al., 2012). A meta-analysis revealed that in patients with a dual diagnosis of coronary heart disease and depression, SSRI medication decreased depression symptoms as well as patient readmission for coronary heart disease. As such, current studies are supporting that SSRI’s may improve coronary heart disease prognosis (Pizzi et al., 2011); thus, further illustrating a heart–brain connection. Studies such as these are bridging the gap between understanding how coronary disease patients treated with certain medications may have synergistic effects. This interdisciplinary research is further suggesting that SSRI patients with improved heart function may be more likely to engage in other healthy behaviors such as mental health-seeking (Pizzi et al., 2011).

Counseling and heart disease

It is a well-established fact that counseling services and therapy can reduce depression and anxiety (Ali et al., 2003), two major contributors to heart disease (Feola et al., 2013). In fact, depression can lead to chronic illnesses such as obesity, hypertension, and coronary heart disease (Blaine, 2008; Niranjan et al., 2012). Pizzi et al. (2011) describes this connection, “The occurrence of depression in patients with coronary heart disease has been shown to substantially increase the likelihood of a poorer cardiovascular prognosis” (p. 972).

As such, counseling can be a great tool to reducing the risk of heart disease. Findings support this, as LeFevre (2014) found that patients enrolled in behavioral counseling had a decrease in heart disease risk factors, including a reduction in fasting blood glucose levels and in blood pressure and lipid measures. Health education and stress management counseling programs have revealed a reduction in cardiac mortality by 34 percent and heart attacks by 29 percent (Dusseldorp et al., 1999). Behavior therapy for patients after myocardial infarction or coronary bypass has been shown to reduce patient psychological distress (Brown et al., 1993). Rutledge et al. (2013) also found that patients with coronary heart disease that received mental health treatments reduced their chances of coronary heart disease. In addition, research supports that continual mental health treatments are a necessary part of cardiac rehabilitation (Rutledge et al., 2013). While the connection between mental health counseling and improved cardiac outcomes is evident, how to infuse such a relationship into the current healthcare system can remain a challenge.

Solutions to improve value-driven healthcare

This discussion of how to improve outcomes in either heart disease or depression/anxiety disorders could not be timelier given the value-driven rework of the healthcare system. Both conditions consume significant time and costs. From the cardiac care perspective, heart patients receiving follow-up treatment guidelines are less likely to adhere to a cardiologist’s medication regiment (Cramer, 2002). This, in turn, may result in additional costly testing and treatment if the condition worsens or another preventable coronary event occurs. The majority of the proposed solutions to address this problem have been from the technology community, whereby smartphones or e-medicine solutions track or send reminders (Santo et al., 2017). These systems, which would ultimately also require patient compliance, are not psychosocial based. Counseling programs, if guided effectively, would have an advantage over unmonitored technology. Furthermore, to this point, a large majority of elderly patients are not technology savvy and are likely to value human interaction more than electronic tools (Peck, 2011). Furthermore, we suggest that from the physician perspective, it would be seen as more efficient to work with established protocols in the mental health community as part of a patient’s overall experience, rather than learning another administrative technology as an attempted solution.

Mental health counseling services in the grand scheme of healthcare reform, we assert, offer a win–win proposition for both patients and providers who are frustrated with the status quo. Even with current reforms shifting to a “pay for quality over quantity” mentality, solutions more often than not are either additional treatments for either the heart or mental health separately, or through dehumanized electronic means to aid patients (Peck, 2011). A counselor or allied health professional that can connect these high-risk patients to already available services that they might not have discovered otherwise, would be of immediate, high impact. A common denominator in both patient and provider qualms with the current system is the amount of human interaction. Presently, physicians are being forced into “quality managed care” schemes that actually reduce patient contact time spent per visit. Patients desire more physician interaction and personal support to learn their best possible recovery plans, which could include outside services in-line with the standard of care (Peck, 2011). The integration of a mental health counselor into this juncture could be the link to provide more human interaction, while at the same time supporting referrals to wellness programs that would support mental and physical health. Given the overlap between mental health and heart disease, it seems likely that healthcare costs would ultimately decrease with a more holistic approach. Mental health counselors however would require additional education to fill this interdisciplinary gap.

This topic has come front and center in the healthcare reform discussion since both physicians and patients desire to increase their own connection to more personalized care (Ciardiello et al., 2016). The response from the innovation arms in most hospitals have been that of developing more impersonal information technology, such as machine learning embedded in complex systems (Santo et al., 2017). These analytical tools simply serve to increase physician operations and data-driven outcomes for payment incentives, based on quality measures. Despite being innovative in their own regard, these means of reform have no clear path on how to integrate mental health or educational services to improve the physician patient interaction and or mental healthcare. As such, we suggest bridging this gap through specific recommendations for clinical healthcare providers.

Recommendations for clinical practice

It is our recommendation that healthcare providers increase their training and knowledge on the intersectionality of the whole patient, including from both a physical and mental health perspective. All too often physical healthcare providers may neglect to consider the mental health impacts on their patients’ physical outcomes. At the same time, while mental health providers may assess for co-occurring physical conditions of their patients, they may lack a fundamental understanding of how the mental and physical conditions impact one another. This lack of psychosomatic understanding and consideration can be especially true in select countries, such as China (Wei et al., 2016), where there is a dire need to increase trainings on the intersectionality of mental and physical ailments.

Licensed physical and mental healthcare providers should increase their knowledge on the intersection between both areas of health. Viewing patient health through a psychosomatic lens is a vital component to providing the best patient care possible, a goal which is an ethical responsibility (American Counseling Association, 2014; American Psychological Association (APA), 2002). As state licensing boards require the completion of continuing education units, it is suggested that a specific focus in the described area be made a part of the requirement. Interdisciplinary partnerships and collaborations should be encouraged and take place as much as possible, and this includes seeking outside sources of training and professional development, including practitioners from other fields.

Often considered the “bibles” of physical and mental healthcare providers, are the International Statistical Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 2004) and Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-V; American Psychiatric Association, 2013), respectively. However, both works lack consideration of the integral connection between physical and mental health. For instance, the DSM-V describes multiple mental health disorders to be present only when the criteria is not otherwise the result of a physical condition (i.e. a brain tumor that causes symptoms of schizophrenia). While the DSM-V may at times mention a consideration of physical health, it does not go into any detail, apart from diagnosis exclusions, of how physical health conditions can impact mental health (i.e. how a history of heart failure can be increase depression). Such connections are especially important for practitioners to be aware of as their clients may need to be asked certain questions of assessment because they too may not even be aware of how such conditions are impacting different areas of their own health. Given this interdisciplinary gap, the authors recommend the intentional inclusion of the impacts of physical health on mental health, and vise versa, to be included in such gold standard references. Given the fact that some countries are less accepting of psychosomatic health as a concept (Wei et al., 2016), we do acknowledge the country-to-country differences in ease of adaptability and implementation of our recommendations.

Recommendations for clinical training

From a counselor education perspective, the academic training of future counselors should include additional material, and courses related to the physical/mental health connection. For instance, as many counseling programs already have a diagnosis course in place that covers topics such as depression, these academic conversations should also include information about how depression impacts physical conditions such as heart disease and vice versa. Counseling programs may also consider specific courses related to the understanding of this physical/mental health connection, including the importance of the standard of assessing for such an existence. Clinical students should consider a physical health perspective as well as mental health during diagnosis and treatment courses. For example, when learning about a diagnosis such as major depressive disorder (MDD), students would read and discuss the literature surrounding the connection between physical ailments and causes of MDD, as well as physical ailments that appear to manifest following life with MDD. During their clinical practice experiences, students would infuse this perspective when actually working with clients.

Finally, many counseling and related educational programs are in-line with accreditation bodies (Counsel for Accreditation of Counseling and Related Educational Programs (CACREP), 2016), which establish strict standards and best practices. As such, a most ideal future scenario would be that accreditation bodies recognize and put forth the need and requirement for educational programs to include this interdisciplinary training and perspective.

Conclusion

Ever more increasingly, the lines between mental health counseling and traditional medical healthcare have significant overlap, and this could be a unique interdisciplinary opportunity for the sharing of knowledge between disciplines, resulting in the treatment of patients and clients from a holistic perspective, with improved overall outcomes. It is logical to conclude that in the new era of value reimbursement based care, the general motivation to implement relatively low cost mental health programs that ultimately improve long-term outcomes at a margin of the standard of care costs is attractive for payers. Finally, restoring human-to-human contact again with less reliance on complex technology is something that both physicians and patients alike desire. Thus, educating future counselors and mental healthcare providers to prepare their skills for this exciting interdisciplinary synergy is a unique, untapped opportunity.