Kim Smolderen, a new faculty member at the Yale School of Medicine, believes that, for the 40% of women at risk for anxiety, screening for it isn’t enough — mental health care needs to be more accessible.
In an op-ed for the Annals of Internal Medicine published June 8, Smolderen, with co-author and Yale colleague Matthew Burg, emphasized the importance of providing access to treatment for women who screen positive for anxiety.
Smolderen and Burg’s op-ed refers to a list of 27 criteria the Women’s Preventative Services Initiative recommends clinicians use to screen adolescent and adult women for anxiety. The WPSI’s list is sound, Smolderen said — but screening will do little to ensure better outcomes if it isn’t accompanied by improved access to treatment.
At Yale, Smolderen is a member of the Interventional Cardiology team. Her research focuses on improving outcomes for patients with peripheral arterial disease, or PAD. After arriving at the School of Medicine in February, Smolderen co-founded the Yale Vascular Medicine Outcomes program, or VAMOS, one of few programs of its kind in the U.S.
A JAMA Network Open study published June 23, which Smolderen co-authored, found links between increased stress and negative health outcomes for PAD patients. Although the nature of these links is still unclear, Smolderen hopes her efforts will lead to holistic care models.
YaleNews talked with Smolderen recently about her research. Interview edited and condensed.
How has your background as a medical psychologist influenced your concerns about screening for anxiety?
In my training as a practitioner as well as in my research, the mind-body connection has always taken a central place. I primarily focus on cardiovascular populations and the role mental health plays in their risk of adverse outcomes and in their recovery. I also try to highlight the importance of integrated psychological care for vulnerable populations and document the mental health blind spots in daily care and health delivery systems.
The advisory issued by the Women’s Preventive Services Initiative on screening for anxiety in adolescent and adult women notes there is a lifetime prevalence of anxiety disorders in up to 40% of women. We simply cannot disregard that, and must realize how big of an impact this has on individuals, their families, and society at large. We need a serious effort to make our care and support systems better able to address this health care crisis.
What would a positive screening for anxiety mean for those women who don’t have access to treatment?
It is unclear whether the act of screening will link people to treatment in case of a positive screen. If there are obstacles that prevent individuals from having access to treatment, individuals remain exposed to the risks of an anxiety disorder. I do want to emphasize that awareness for mental health is a great first step, and that this problem no longer remains ignored. Having a wider discussion about preventive approaches and better care pathways has to go hand-in-hand with this greater awareness, though.
You mention in the op-ed that mental health screening is likely only to be effective within a collaborative care context. What does collaborative care look like?
Collaborative care models have been primarily designed and used in a primary care setting. Care managers, including mental health care providers, use evidence-based care programs and continuous monitoring of the anxiety and/or depression symptoms of the individual undergoing treatment. This type of care context allows for a proactive, patient-centered, and evidence-based treatment protocol while maximizing effective communication between the different care actors and the patient.
What’s the relationship between mental health and heart health?
In the scenario of stress or other psychological risk factors, there are direct physiological pathways such as increased inflammation.
There is a strong association, but the pathways are complex and multidirectional. In the scenario of stress or other psychological risk factors, there are direct physiological pathways such as increased inflammation, platelet reactivity, and an imbalance of sympathetic and parasympathetic activity (which means that your fight/flight response goes into overdrive). These mechanisms may predispose you to a higher cardiovascular risk. When feeling down, you will also be less likely to eat well, exercise, or sleep well, and engage in other unhealthy behaviors such as smoking. These health behaviors may, in addition, indirectly increase your risk for cardiovascular disease. Individuals with mental health concerns may also be more likely to delay seeking medical care or follow medical advice or take medications.
In a recent study of patients with peripheral arterial disease (PAD), you found evidence for a link between mortality rate and chronic stress levels. Can you describe this link?
We are at the early stages of understanding how mental health interacts with and impacts outcomes in PAD. Recently we have been linking depression with PAD-specific health status outcomes and have seen it is one of the strongest correlates of poor health status outcomes. We also found that stress levels [in PAD patients] are very high and tend to be chronic. And with chronicity comes an increased risk of long-term mortality. For PAD in particular, it is unclear which pathways are most impactful, but we are now focusing on studying the role of exercise, hypertension, smoking, and social support. We hope that for this vulnerable group of patients we could design and test integrated care models that address their disease from a holistic perspective.