Peripheral artery disease (PAD) is a cardiovascular condition in which plaques accumulate in the arteries that supply oxygenated blood to the limbs, restricting blood flow. When the legs, the limbs most commonly affected, have too little oxygen, they hurt, and in severe cases, the oxygen-deprived tissue dies, sometimes necessitating amputation. In addition to these physical symptoms, people with PAD have higher rates of mental health problems than the general population. Integrating mental health care into PAD treatment is essential to caring for people with PAD and may also improve their cardiovascular outcomes argues a scientific statement, which Yale faculty co-authored, by the American Heart Association (AHA). The statement appeared October 2 in the AHA journal Circulation.
The possibility that treating the mental health problems of people with PAD may also improve their PAD outcomes is tantalizing because advances in the medical treatments for PAD have reached something of a plateau, according to Carlos Mena-Hurtado, MD, FAHA, FSCAI, associate professor of medicine (cardiology) and senior author of the statement. “We’re giving patients everything we got,” he says, be it medications to slow the accumulation of arterial plaques or surgeries to bypass or replace damaged blood vessels. “We quickly realize that there's something else to the story that is not being addressed or studied. And that's where the issue of mental health becomes relevant,” he says.
People with mental health problems are entitled to treatment, full stop, adds Kim Smolderen, PhD, MSc, associate professor of internal medicine and psychology, co-director of the Vascular Outcomes Program, and leading author of the statement. “The fact that they are carrying this higher burden deserves treatment in its own right,” she says.
Researchers have been investigating the relationship between mental and cardiovascular health since the 1950s, when the focus was on the links between stress and coronary artery disease. In studies of people with coronary artery disease, who have a high mental health burden, treating depression has been found to improve quality of life, and offering multi-component psychological interventions, including relaxation training, teaching coping skills, cognitive restructuring, and psychoeducation, has been associated with improved prognoses in heart attack survivors. Based on the available data, Smolderen and Mena-Hurtado thought there might be a similar relationship between mental health and cardiovascular outcomes in people with PAD. Additionally, in recent years, the PAD population has included more younger people, who tend to have more mental health problems, including substance abuse and stress-related disorders. To raise awareness of mental health considerations when treating people with PAD, Smolderen and Mena-Hurtado proposed an AHA scientific statement on the topic.
Smolderen and Mena-Hurtado gathered a multidisciplinary committee of PAD experts and conducted a literature review focusing on the intersections between mental health and the risks of developing PAD as well as its treatment and outcomes. The group wrote the statement collaboratively.
There is some evidence that depressive symptoms, anger proneness, and low social support increase the risk of developing PAD, but most research about mental health and PAD focuses on people who have already been diagnosed with PAD, Smolderen says.
People with PAD are more likely than the general population to have depression, anxiety, and chronic stress. One reason for this may be that people with PAD experience leg pain and respond by exercising less; they thereby lose the protective benefits of physical activity that may help regulate mood, Smolderen says. Also due to pain and the high burden of procedures some patients may be facing, people with PAD are also more likely than the general population to be exposed to opioids at high levels, which puts them at risk of developing opioid use disorder. Individuals with severe PAD who need to have a limb amputated may also experience feelings of depression and grief, she adds.
Mental health problems are associated with worse outcomes in people with PAD: Patients with PAD and depression have higher all-cause mortality, longer hospital stays, and lower medication adherence than patients who aren’t depressed. Why might this be? A key part of treating PAD is for patients to make lifestyle changes, such as exercising more, quitting smoking, and eating better. People who are depressed tend to have more difficulty making those lifestyle changes, Smolderen says.
Researchers hope that treating patients’ mental health problems will improve their PAD outcomes, but there has been little research on this topic. Studies have found that motivational interviewing, where an interviewer asks questions designed to help people reevaluate their beliefs, and cognitive behavioral therapy have helped people with PAD stick to exercise programs, Smolderen says.
For areas where PAD-specific research is not available, the statement recommends adapting the knowledge about mental health and other cardiovascular diseases to help people with PAD. For example, the statement suggests exercise, cognitive behavioral therapy, and medications to manage depression and anxiety. To prevent opioid addiction, the statement recommends developing multimodal pain management strategies. The statement also advocates for developing trauma-informed care, especially to help patients who undergo amputations. To gather needed data, Smolderen and Mena-Hurtado recommend studying the effectiveness of these interventions in PAD patients, in terms of both mental and cardiovascular health.
To implement the recommendations of the scientific statement, it will be necessary to integrate mental health care with other aspects of PAD treatment, something that has not been done before. This in turn will require incorporating mental health into medical training, Mena-Hurtado says. “The importance of the statement is to raise awareness, and to create a pathway for future generations to be trained and understand what this will look like in the future,” he adds.
The work of the investigators on this study was funded by grants from Janssen, Merck, NIH (R01HL163640; 1R21AT012430), Abbott, Shockwave, Philips, CDC/Department of Health, NIH (Heal Program: Pain in CLI). In addition to Smolderen and Mena-Hertado, authors of the scientific statement include: Carole Decker, PhD, University of Missouri, Kansas City; Tracie Collins, MD, MPH, MS, University of New Mexico College of Population Health; Nathan Itoga, MD, Stanford University; Ronald Lazar, PhD, FAHA, University of Alabama at Birmingham McKnight Brain Institute; Zainab Samaan, MBChB, MSc, DMMD, PhD, FRCPsych, McMaster University.
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