An interview with Ashley Borgatta, LCSW MHA byt James Miller, LCSW on BCTV’s Talking Mental health.

Enjoy this conversation or find the full interview here

The Interview 

Mr. Miller: How did you get involved in the collaboration of both physical health and mental health?

Ms. Borgatta: Growing up I was always interested in the medical field as my father is a Cardiologist for  Berks Cardiology, now part of Penn State Health at St. Josephs. However, through my years of education, I realized I did not want to be directly in the medical field and that I was drawn to psychology and behavioral health.  After getting my Clinical License in Social Work I began to find more often that our patients behavioral health is greatly impacted by their physical health. So when my dad invited me to a talk by Dr. Samuel Sears on Cardiac Psychology I just could not pass up the offer.  Dr. Sears is a Professor at East Carolina University Departments of Psychology and Cardiovascular Sciences and Director of Health Psychology. I became fascinated with this link and the realization that often times both fields forget to care for the patient as a whole.

Mr. Miller: So what exactly is the psychology of cardiac care?

Ms. Borgatta: Cardiac Psychology is a specialization of psychology that focuses on the primary and secondary prevention of heart disease. This is done by incorporating strategies that address both the emotional and behavioral barriers to lifestyle changes associated with heart disease and aims to enhance the recovery process by providing healthy coping skills to manage these changes.  It can be beneficial across the cardiac patients lifespan, through prevention, pre-surgery, post-surgery, and rehabilitation with emphasis on quality of life outcomes.

Mr. Miller: What is the prevalence of psychological distress in cardiac patients?

Ms. Borgatta: Well, this actually can be broken down into two categories.  First we would have to look at the prevalence in patients with implantable cardioverter-defibrillators or ICD’s.  For those who are unaware, ICD’s are devices that are implanted inside a patient’s body and they are able to monitor for life threatening slow and fast heart beats.   If a slow heart beat is detected it will pace the heart, and if a fast heart beat is detected it will shock. Second we would look at the prevalence for those patients who diagnosed with atrial fibrillation, or A-Fib.  A-fib is an irregular, and often rapid, heart rate that commonly causes poor blood flow.

Mr. Miller: Alright, so what are the prevalence rates for patients with ICD’s?

Mental Health Stats

Ms. Borgatta: First off, I would like to preface that many of my statistics I will be providing today come from various research articles and presentations by Dr. Samuel Sears as he is considered an international authority on the psychological care and quality of life outcomes of patients with implantable ICD patients and has published over 100 articles in the medicine and psychology research literatures.  ICD patients and families present with many different types of worries including, but not limited to, ICD shock, device malfunction, device recall, fears of pain or embarrassment or even fears of death Psychological distress is extremely common for cardiac ICD patients, with approximately 13-38% of ICD patients experience anxiety and anywhere from 24-48% of patients experience significant depressive symptoms.   These rates increase based on the patients experience and proximity with ICD shocks.  The closer a patient is to a previous shock, the more likely they are to experience anxiety of being shocked again.  Meanwhile, the greater time since the shock is associated with a decrease in anxiety. However, research has shown that even 6 months post shock, the shock anxiety still remains elevated and therefore it is believed that the experience of an ICD shock has immediate and long-term negative effects on patient’s disease-specific quality of life.

Mr. Miller: And what about for patients diagnosed with A-Fib?

Ms. Borgatta: For patients with intermittent A-fib, approximately 54% report psychological stress as the most common trigger. Patients with worsened severity of depression and anxiety report an associated increase in the severity of their A-fib symptoms.

It is important for physicians and patients alike to be aware of this as these increases were also associated with increased visits to both outpatient clinics and hospitals for A-fib management. 

This means that the psychological well‐being of a cardiac patient may strongly influence symptom severity and healthcare utilization.

Mr. Miller: So why is Cardiac Psychology so important to patient’s wellbeing?

Ms. Borgatta: This basically boils down to working toward improving the patient’s quality-of-life , in their physical health, emotional health, and social activities.  When working with patients, their common concern is for their overall well-being and not the actual functionality of their heart.  Patients often make their healthcare decisions based on personally relevant outcomes, such as their quality of life.  If they are unable to live a life similar to what they desire, they often may chose a different option of care. While many of the concerns can be addressed by a patient’s cardiologist, other concerns will require the patient to be referred for more extensive psychosocial treatment.

Mr. Miller: What are the predictive factors for cardiac psychological distress?

Ms. Borgatta: The most common predictive factors include individuals who are younger than age 50, female, and those who may have experienced an ICD shock.  However, another important factor to look out for is physical activity rates.  In a 2018 study by Dr. Sears, it was found that baseline device-detected daily physical activity was low in most patients with an ICD, at a rate around 3 hours per day.  And this rate significantly declined after experiencing an ICD shock. While activity did gradually increased as time post shock increase, low levels of activity were found to be independently associated with a 2.5 fold increase in risk of hospitalization within the next 30 days.  The study also found that an overall lower baseline of physical activity was associated with a 40% increase in mortality 4 years post ICD implant. Therefore, given the known associations between low levels of physical activity, psychological functioning, and adverse cardiac events, it is reasonable to assume that patients with an ICD who experience shock and a prolonged decline in physical activity may have an increased risk of hospitalization, morbidity, and mortality. 

Mr. Miller: What are the types of treatment?

Ms. Borgata: There are several different avenues to provide psychological health benefits for cardiac patients. Firstly, for patients with an ICD, there should be ICD-Specific Education.  This aims to help patients understand why they have an ICD and how it protects them.  The goal here is to debunk any myths about the causes of ICD shocks, like exercising causing a shock.  This education most likely will start with the patient’s cardiologist but can be reinforced by a cardiac therapist.

Secondly, patients should receive training and education on Relaxation/Stress Management techniques, or coping skills as they are so often called. These techniques aim to assist patients in reducing their ongoing hyper-vigilance post shock or irregular heart beat.  Coping skills also help to reduce general stress and anxiety symptoms that can sometimes mimic irregular heart beats and therefore may cause additional concern when your heart is actually working properly.

The third avenue would be to employ the use of Cognitive Techniques.  The goal here is to help patients identify their attitudes and beliefs about themselves, their health, any cardiac device they may have, and the future.  This would better help the patients to identify their feelings about surviving cardiac disease, help them to recognize the feeling of safety that an ICD could provide, and learn how to reimplement a healthy lifestyle to improve their quality of life.

Lastly, it is important for patients to be able to participate in Group Discussions and Peer Social Support.  This is extremely beneficial as it allows for the patient to share in the experience and to be be exposed to similar views and feelings about cardiac wellbeing.  It will also provide patients with a clearer sense of safety as they see other individuals regain their life post cardiac disease. 

Mr. Miller: What are the rates of relapse?

Ms. Borgatta: Studies show that psychosocial treatment for cardiac disease was associated with positive changes in adjustment and functioning.  In a 2007 study by Dr. Sears, it was shown that individuals who were treated weekly for six weeks were able to show a more rapid decrease in overall cardiac anxiety.  However, this difference did not persist in long-term follow-up.  It is therefore evident that continued psychological care, especially post ICD shock, is necessary to sustain improvements in depression and anxiety for cardiac patients. For this reason, it is important for mental health professionals and cardiologists to encourage patients to receive ongoing treatment to address overall health quality of life.

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