By Clarissa Donnelly-DeRoven
When cardiac patients visit the East Carolina Heart Institute in Greenville, they see the usual providers – internal medicine doctors, cardiologists and nurse practitioners. They also might sit down with a cardiac psychologist, a mental health professional who specializes in supporting people as they navigate the complicated emotions that arise with cardiac issues such as heart attack, heart failure and open heart surgery.
At the facility, prospective psychologists and cardiologists train alongside each other and then go on to work side by side, co-treating patients. A new article in the Journal of Health Psychology explores how the facility’s partner school — East Carolina University — has grown its cardiac psychology training program into one of the best in the country.
Only Yale and East Carolina are noted in the special edition, said Sam Sears, a clinical cardiac psychologist and the director of the ECU department.
“It’s hard to say we’re the only one,” Sears said. “But there’s really nobody that’s created this kind of synergized, integrated, one-for-one engagement in the training of cardiologists and the training of psychologists.”
All of the psychologists in the program are trained mental health professionals who also learn the fundamentals of cardiology, both so they can understand each patient’s diagnosis, and so they can work alongside a patient’s medical team with ease.
Kayla Sall is the lead author of the new study and a fourth-year doctoral candidate in clinical health psychology at the school.
“It’s very rare to find cardiac psychologists that are co-located in cardiology,” she said.
Her experience in the program, and the approach she and other researchers document in their new article, show what a critical role these providers can play.
“When patients come to us, sometimes they will be hesitant and be like, ‘Are you saying that this is all in my head? Why am I being referred to you?’’ Sall recalled. “But, I think they are very reassured when they realize the depth of knowledge we have when it comes to cardiology, and that we’re pairing that with psychology.”
While the program might sound niche, there’s no reason it should be. Heart disease is the leading cause of death in the U.S. and the second leading cause of death in eastern North Carolina. Of the 10 counties with the highest five-year mortality rate from heart disease, all five sit east of I-95, and three of those are coastal.
The cardiac death rate in this part of the state has been declining for nearly two decades, nonetheless it remains higher than the overall state rate. It’s also higher than the rate among rural NC in general, according to an analysis by researchers in ECU’s Department of Public Health.
“This region, like many rural regions, has substantial health inequalities associated with poverty, associated with lack of health insurance coverage, associated with lower income, lower education, and less access to health care resources,” Sears said.
A significant “saving grace” for patients, as he puts it, is the existence of the university, its medical center, and both of their relationships to the community.
“Our program is intending to lead the country in this,” he said. “We’re not just simply filling in a hole. What we’re trying to do is say: this is the way to do it.”
Leading with the head or the heart?
There are decades of research and observations documenting that people who have heart problems often end up depressed and anxious.
These mental health problems and heart disease feed each other. A 2010 analysis found that people suffering from anxiety had a 26 percent increased risk of developing cardiac disease, compared to their non-anxious counterparts. Other studies have found that people with depression have platelets that clot more easily, those are the components in the blood that allow blood to form clots to begin with. Researchers refer to these platelets as ‘sticky’ — which can increase a person’s risk of heart disease.
When someone’s depression is treated, some research has shown these tiny blood cells can become “less sticky,” and thus less likely to cause heart problems, though the conclusion isn’t definitive.
On the other end of the feedback loop, studies have found that among patients who’ve been diagnosed with heart failure, a third said they were anxious and a third said they were depressed.
For example, research on patients with implantable cardioverter defibrillators — devices that a surgeon puts into the body to zap the heart if it starts beating irregularly— has found that between 20 and 40 percent report experiencing significant anxiety about the new implant.
When the device is activated it delivers an electric shock that patients describe as feeling like a horse kicked them in the chest. There’s no telling when the shock might come again, if ever.
“I think that is the scary part,” Sall said. “They agree to have this device implanted. They know it’s life saving. But you don’t know when the shock is gonna go off.”
Sometimes, Sall said, the anxiety and fear patients develop about the shock can grow so much that they’re diagnosed with post-traumatic stress disorder.
Cognitive behavioral therapy, for the heart
When Sall enters a room with a new patient, she says hi, and asks to hear their “cardiac story.”
“We’ve already completed extensive medical chart reviews,” she said, “But we want to hear from their perspective.”
The clinicians ask patients about their background and how their cardiac disease has impacted their daily life. But, they don’t go so in-depth that they scare people off.
“We don’t need to do a deep dive into their past, their childhood,” she said. “It’s much more focused on the cardiac side of things and how that is impacting their behavioral health and their mental health.”
While the treatment and approach change from patient to patient, much of it takes the form of cognitive behavioral therapy, considered the “gold standard” of psychotherapeutic interventions. The technique helps patients identify negative or destructive thought patterns and change their automatic responses.
“We work to kind of help people understand what they’re experiencing,” Sall said. “It’s okay to be fearful and that’s a normal response, but we need to also be able to use some relaxation techniques to calm down the anxiety.”
Behavioral change without the shame
Cardiac psychologists are often tasked with pretty concrete goals. For example, to help patients improve their heart health, they need to help them stop smoking or lose weight or exercise more.
In a conversation with a patient about quitting smoking, Sall will often start by asking, “Zero to 10, how motivated are you to quit?” If a patient says something other than zero, she follows with: “That tells me that there’s something that makes you want to quit.”
The goal is to help patients find balance, to help them identify what they want, and to make a change that will feel good and in line with their goals and values.
Her approach works most of the time, she said, but sometimes it doesn’t. When people say zero — no way they’ll quit smoking, they love it, best part of the day — she doesn’t push it. That’s not what she’s there for.
“The scare tactics typically don’t work,” she said. “Just telling someone [to] stop smoking, telling someone it’s gonna give them lung cancer, it’s gonna kill them one day — that’s not a very empathetic approach, right? You need to meet people where they’re at.”
Also, it’s rare that there’s only one thing negatively impacting a patient’s health. If someone doesn’t want to stop smoking, there are other things they could change to help their heart be healthier.
As a clinical health psychologist, Sall said, she’s there to help patients figure out their priorities. In other words, “What is the most feasible? And what’s most important?”