Yale Psychiatry Grand Rounds: April 29, 2022

April 29, 2022

"Broadening Cardiac Psychology: The Case of Vascular Disease and Integrated Cardiovascular Behavioral Health Care"

Kim Smolderen, PhD, Associate Professor of Medicine and Psychiatry, Yale School of Medicine

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00:00Q All for being here this morning
00:02and to for the opportunity to
00:05present in today's grant rounds.
00:07It's my great honor.
00:08The topic that I would like to
00:10highlight today is the emergence of
00:12the field of cardiac psychology and
00:14to make a case how we should broaden
00:17it to include vascular populations and
00:20how both cardiac as well as vascular
00:23populations all would benefit from
00:25integrated cardiovascular, behavioral
00:27healthcare in the specialty setting.
00:31These are my disclosures.
00:36I would like to dedicate today's
00:38lecture to my great mentor,
00:40alluded to in the introduction,
00:43who has been a great support
00:44throughout my career.
00:45Yohan done on it also
00:47Belgian native like myself.
00:49Whose theory focused on a
00:52combination of personality traits
00:53that proved to be particularly
00:56toxic for cardiovascular outcomes.
00:58Without his encouragement and support,
01:00I would not stand here today and so
01:03his work and passion for the field
01:06has definitely been passed on to
01:08many of us who have spread out and
01:10trained under him and all of us have
01:13spread out over the world to continue
01:15the the work that is ahead of us.
01:20So for today's presentation,
01:22I would like to take you back to
01:25some of the origins of health,
01:28psychology and some of the defining
01:31moments as a response to the
01:33post war chronic disease burden.
01:35And following that I would like to
01:37zoom in on further subspecialization
01:39that occurred and as an example would
01:42like to highlight the feel of cardiac
01:45psychology and the research and the
01:47interventions that led up to it.
01:49Next I would like to broaden the
01:51focus to include populations with
01:53vascular disease and those as those
01:56have been the primary focus of
01:58our work and I will conclude with
02:00making the case for integrated
02:02behavioral health care for both
02:04cardiac and vascular populations.
02:09So before we dive back in history,
02:12I want to highlight what the
02:15American Psychological Association
02:16today defines as health psychology.
02:19They defined as discipline as a discipline
02:23that examines how biological, social,
02:26and psychosocial factors influence
02:28health but also illness and health.
02:31Psychologists use their psychological
02:33signs to promote health to prevent
02:36illness and improve healthcare systems.
02:38So I want you to keep in mind that
02:41definition as we dive into today's lecture.
02:46So some of the historical origins of the
02:48field are traced back to the post World
02:51War Two period where how psychology
02:54really emerged as a reaction to some
02:58of the changing phenomena in society.
03:02First of all,
03:02we saw a decline of infectious diseases,
03:05but at the same time also a rise of chronic
03:07conditions due to the changed lifestyle,
03:10working and living conditions in the
03:14populations in industrialized nations.
03:17And the origins of health psychology
03:21technically can be traced back
03:23in in the US to this publication
03:26of Williams Schofield in 1969,
03:28where the Roll of Psychology in the
03:31delivery of health services was a
03:34report that was published by the
03:37American Psychological Association
03:39in the American psychologist.
03:41And all over the world we saw
03:44similar developments taking place,
03:46and as an example,
03:47French psychology after World War Two.
03:50Increasingly clinical psychology was
03:52being delivered in health settings.
03:55It was influenced by psychoanalysis,
03:59social and clinical psychology
04:01and psychopathology,
04:02and so this blend,
04:03in addition with the influence of
04:06American social psychology,
04:08social cognitive theories of health
04:10and illness.
04:11Brought it together to this health
04:14psychology field that emerged.
04:16And increasingly,
04:17this new discipline was being disseminated
04:20in the hospital setting and in the public
04:23health sphere and all around the world.
04:25We saw similar developments taking place,
04:27such as in the UK,
04:29Brazil, South Africa,
04:30the Netherlands, Australia,
04:31and elsewhere.
04:36Other key critical developments that
04:39allow this new discipline to emerge is
04:42really a variety and and a fortunate
04:45set of circumstances and and critical
04:48breakthroughs down to we saw evolve.
04:51So first of all, we had high-quality
04:54epidemiological evidence how behavior
04:56and disease incidents were causally
04:58related and the most prominent
05:00example of that is smoking behavior
05:03and the incidence of lung cancer.
05:06So that is an important development
05:08that took place and then with the
05:11rise of the chronic health burden.
05:13Of course came also the rise of the
05:15cost of healthcare and the need for
05:17more effectiveness and efficiency in
05:19the delivery of health care and health.
05:21Ecology was one of the responses to that.
05:25At medical schools we saw also an
05:27uptake in teaching of behavioral
05:30sciences as a part of the curriculum
05:32and an increase in communication skills
05:36training to improve patient adherence,
05:38patient satisfaction satisfaction.
05:40So an increased focus and an openness to
05:44that in the medical schools was taking place.
05:47We saw more and more clinical psychology
05:50behavioral medicine also moving
05:52into the primary care setting and
05:54collaborative care models being offered.
05:56During this era also we had important
06:00theories for behavioral change
06:02models being developed,
06:03tested and used for interventions
06:06with evidence based interventions
06:08that we still use up until this day
06:12that were developed during this period
06:15and we actually became pretty good
06:17in predicting health behavior change
06:19with an emphasis on health beliefs,
06:22attitudes and behavior.
06:25And then another parallel of development
06:28was the field of second neural immunology,
06:31where we really saw the relationship
06:33between the immune system and the
06:36central nervous system and the role
06:37of stress being documented in a in
06:40a very detailed way,
06:41and then finally unfortunately the
06:43AIDS and HIV epidemic in the 80s.
06:47Also spurred funding in behavioral
06:49health research,
06:50so those developments were critical
06:53for this discipline to emerge.
06:57Yale had a very important role also
06:59in helping to shape this field of
07:02health technology with yields,
07:03President Peter Salovey being one of
07:06the Inspirators who helped define the
07:09field with others and highlighting the
07:11fact that people sense of their own health,
07:14is not only the reflection of their
07:17psychological and physical well being,
07:19but also a good predictor for
07:22subsequent physical health and how
07:24these two are are really intertwined.
07:30Further formalization took
07:32them place with in 1976.
07:36The establishment of the Division
07:3838 that was referred to in the
07:41beginning of of the introduction.
07:43Where the American Psychological
07:45Association established a separate
07:47division directed towards health psychology
07:50and which is still up until today.
07:52Very active.
07:54You had also one of the foundational
07:57conferences that really brought behavioral
08:00health and biomedical scientists together.
08:03How we should together solve
08:05problems of health and illness
08:07in an interdisciplinary way.
08:09And this was led by Gary
08:11Schwartz and Stephen Weiss.
08:13And then in the early 80s,
08:14the Arden House Conference really
08:18scoped out the professional
08:20responsibilities and the training
08:22requirements for health psychologists.
08:25So together these multidisciplinary
08:27developments and professionals
08:29promoted the importance of behavioral
08:32health and and spurring more research
08:34and education in this domain.
08:40So in the next part I would like to zoom
08:43in more on the further subspecialization.
08:45Since this new discipline
08:48emerged and the observations,
08:50the research that led up to this,
08:52and while not officially
08:54recognized as a subspecialty,
08:56it certainly is emerging and the relevance
08:59of it has become increasingly clear.
09:02So I'm talking about cardiac
09:04psychology as people refer to it.
09:08Also, a little bit of history here that
09:11took place around the same time as health
09:14psychology in general was developing,
09:16taking us back to the work on
09:18type A personality in which I will
09:20talk a little bit more in a bit.
09:22Going from type A personality
09:26to elements of its personality,
09:27anger, hostility, focusing,
09:29then the next wave of research
09:32on depression and the individual
09:34elements of all the types of symptoms,
09:38somatic versus cognitive,
09:40in the toxicity of cardiovascular outcomes.
09:44A related concept where the emphasis was
09:47on fatigue was vital exhaustion that
09:49was also coming from the Netherlands,
09:52studied by apples in mass thrift and
09:55for some of you might be familiar
09:58with the mass Thrift Questionnaire
10:00which was developed over there.
10:02And then further research on
10:05other psychosocial factors,
10:06anxiety and of course a large
10:08body of research on stress,
10:10both acute and chronic stress that
10:13was developed in highlighting.
10:15Again the work of my mentor going
10:18hunting led to a developed a theory and
10:21described the phenomenon of the depressed,
10:23the distressed type D personality,
10:26which is a combination of
10:28negative affectivity,
10:29the tendency to experience negative emotions.
10:32But at the same time,
10:34also scoring high on social
10:36inhibition so people not sharing
10:38their emotions and he documented in
10:42several cardiovascular populations
10:43that that combination is particularly
10:46cardiotoxic as as we refer to it.
10:51So the first description that was
10:54published and where we saw a parallel
10:58trend between people's mindsets and
11:01outcomes for coronary artery disease
11:04was done by a UK physician in 1950.
11:07Where there was a link.
11:11Describe between potentially changing
11:13lifestyle and working conditions
11:15and cardiovascular disease.
11:17And his first letter was met with highly
11:22contested responses to these observations.
11:25So the only thing that this doctor
11:28Stewart noted was that there was an
11:31increase in cardiovascular disease
11:32coronary artery disease during
11:34this century is what he describes,
11:37and that the malady mostly effects men
11:40in middle life and in his further the
11:44scription he refers to the work pace
11:46and notes a parallel between the two.
11:52So that was the first publication in
11:55the UK and then a little later in the US
11:59there was a duel of cardiologists that
12:03presented the work on type A personality,
12:08and Rosamond and Friedman described
12:11as type A personality that was
12:15characterized by an intense Dr.
12:18Need for achievement,
12:19constantly being on the go.
12:22Being very competitive.
12:24Hostile and having high anger
12:28and and and So what they observed
12:32was in this personality profile.
12:35When they contrasted it with other
12:38personality profiles is that they had
12:41a much higher rate of coronary artery
12:43disease and also in their subsequent
12:46work described higher mortality rates
12:49linked with this personality profile.
12:53This construct was only studied in men,
12:56and as the research accrued.
13:00There was some issues with
13:03replication of this work and.
13:06One started to focus on some of the
13:08most toxic aspects of this personality.
13:11Trade anger and hostility,
13:14which then was studied in isolation.
13:17And and so over time this this research
13:19line had gotten out of favor because
13:22there were several issues with it.
13:24And so with that overall,
13:26the study of psychosocial factors
13:29in coronary artery disease.
13:31The enthusiasm for it temporarily lowered.
13:37Until this Canadian dual of researchers
13:39were able to put the interest for
13:42psychosocial factors and cardiac disease
13:45back on the map with their landmark
13:48study published in the 90s in in JAMA,
13:51Nancy, Fraser, Smith and Plasma.
13:54Let's billons they followed in Quebec.
13:58A population of acute micro
14:01cardial infarction survivors.
14:0478% of them was male.
14:07And they were interviewed with a
14:10diagnostic interview for Depression 5
14:12to 15 days following the acute event.
14:15And they simply looked at their
14:17survival state at six months
14:19obtained from medical records.
14:22And what they saw is that upon assessment,
14:25when people had their acute
14:28myocardial infarction,
14:2916% met the criteria of major depressive
14:33disorder at the time of the interview.
14:35And then at follow-up,
14:38the people who died 50% was
14:42marked as depressed at inclusion.
14:45And so the mortality in the press was
14:48much higher than the non depressed.
14:50And all of the mortality causes
14:53were cardiac related.
14:54So the risk that they observed was a
14:57fourfold risk of adverse outcomes.
15:00And so this really opened up this
15:02line of research again and and
15:05gotten a lot of attention.
15:07Why?
15:07Why is this a landmark paper,
15:09even though today we would say this
15:10is a small study, short follow-up,
15:12etcetera.
15:13It reopened a discussion of the
15:16importance of psychosocial and behavioral
15:18factors in cardiac disease outcomes.
15:21And by focusing on depression
15:23as opposed to personality,
15:25it offered a manageable explanation,
15:27for which we know treatments for the
15:30mind body link in cardiac disease,
15:32and importantly this this work for the
15:34first time did not have a gender bias.
15:36It also included women.
15:38And it also offered an important concept
15:42that could serve as an explanation
15:45for the racial and gender disparities
15:47that were Dan already described
15:49in in cardiac disease outcomes.
15:53So since then, people have further
15:56looked at much larger cohorts.
15:582000 plus cohorts in in
16:01a variety of populations,
16:03stable coronary artery disease.
16:07As well as outpatients
16:09heart failure patients.
16:11Longer follow-up periods and.
16:14Essentially,
16:15these these observations
16:16were replicated further,
16:18and then the endpoints that one
16:22became attuned to was expanded
16:24not only to focus on mortality,
16:28but especially the quality of life.
16:30Of these patients that go
16:32through this experience,
16:33adherence issues and lifestyle factors
16:36were also related to the study of
16:39depression in in this population.
16:47The numbers for today that I would
16:51like to highlight that overall we we
16:54find evidence for acute myocardial
16:57infarction survival survivors.
16:59That's about one in five percents
17:01with a major depressive disorder.
17:03And one in three does not meet the
17:07threshold for major depressive disorder,
17:10but still presents with clinically
17:12relevant depressive symptoms,
17:14and it doesn't matter whether people
17:16meet the formal threshold or have
17:19increased depressive symptoms.
17:20They are at risk of subsequent
17:23adverse outcomes, and that has
17:25been multiple times demonstrated.
17:27Unfortunately,
17:28only a third of patients are recognized
17:31as such as depressed during their
17:34acute myocardial infarction admission
17:36even when systematic screening
17:39programs in hospitals are in place.
17:42We do find that there is a large
17:45under recognition of depression,
17:47and the problem is also tied to
17:49the care linkage and the linking
17:52them to appropriate treatment.
17:58Next, I want to highlight a larger global
18:02study that has since then been conducted
18:05and was published in The Lancet in 2004,
18:09which caught a lot of attention in
18:13the space of cardiology and allied.
18:17Specialties that are interested
18:19in cardiovascular populations,
18:20and this was a case control design
18:23where they studied over 11,000
18:26patients who had suffered their first
18:30heart attack and they matched them
18:33with age and sex matched controls.
18:37Control set of over 13,000 individuals.
18:41And they recruited them from
18:44centers around the world, Asia,
18:46Europe, Middle East, Africa,
18:47Australia and North and South America.
18:50And then they measured
18:51the variety of factors,
18:53the risk factors that are known
18:55to be associated with my cardio,
18:57infarction and psychosocial
18:59stress was one of them.
19:01It was assessed with four simple questions
19:04about stress at work and at home.
19:06Financial stress and major life
19:08events in the past year and then
19:11additional questions also ask
19:13people about the locus of control
19:16and the presence of depression.
19:18And here all of these factors that
19:21they studied are listed together and
19:24put together in a model where the
19:27contribution of how much each individual
19:30factor contributed to the risk of
19:33acute myocardial infarction was presented.
19:35Other risk factors studied were smoking,
19:39diabetes,
19:39hypertension, obesity,
19:40intake of fruits and vegetables,
19:44exercising alcohol intake and lipid profiles.
19:48And so when you look at
19:52the psychosocial index,
19:53you see that it was a robust predictor of
19:57experiencing and acute myocardial infarction.
20:00And in this column they also calculated the
20:04population attributable attributable risk,
20:06which is the proportion of the
20:09incidents of getting an AMI in
20:12the population between those who
20:14are exposed to particular risk
20:17factors versus non exposed.
20:19Is calculated and so if you focus
20:23on the rate for women it has a
20:27population attributable risk of 40%.
20:30And so if you translate that that's 40,
20:33it means that 40% of the incidence
20:35of an acute myocardial infarction
20:37in women is due to the exposure
20:39of psychosocial risk factors.
20:41So that was an eye opening study also
20:43for the larger medical community to
20:46acknowledge the role of psychosocial factors.
20:49In cardiovascular disease and
20:51in acute myocardial infarction,
20:53in particular.
20:56So with all this work and follow up,
21:00it became clear that stress
21:02is a significant risk factor
21:03for coronary artery disease.
21:05Both incidents and progression.
21:06It is very common.
21:08It can be confused with cardiac symptoms.
21:10It is linked to behavioral and
21:13cardiovascular risk factors,
21:14and it really forms a barrier
21:16for medical interventions.
21:18And also sometimes it may be a
21:20direct trigger for experiencing
21:22acute cardiac events such as.
21:25Anger has been linked with the
21:28experience of an acute event.
21:33Since this research was proposed,
21:36many also studied underlying mechanisms
21:39that would explain why stress is linked
21:44to atherosclerosis and the following
21:47model has been proposed as the underlying
21:51stress model for cardiovascular disease.
21:54Now with atherosclerosis as the
21:58underlying pathological process,
22:00so chronic stress and affective disorders
22:03that lead to the activation of the HP
22:07axis and the sympathetic nervous system.
22:10And it further affects our behaviors,
22:13how our health behaviors and and due to
22:16the prolonged activation and the imbalance
22:19of the sympathetic nervous system,
22:21there are heightened
22:23physiological responsiveness to,
22:25to acute stressors.
22:27Also interactions with chronic stressors
22:29that further cause more downstream effects,
22:33such as the ones listed on the right,
22:36increased inflammation,
22:37platelet reactivity and endothelial.
22:40Dysfunction to name a few of those effects.
22:46So following these insights,
22:48people also came together to design several
22:51interventions to address depression as a
22:55risk factor for cardiovascular disease
22:57and depression and stress reduction.
22:59Interventions have been developed and
23:02tested mostly in coronary populations and
23:06the most prominent ones highlighted here.
23:09And so these trials they overall were
23:12successful in improving depression,
23:14symptoms, quality of life.
23:16But at the same time,
23:19the hopes and the fields were high
23:21also to be able to reduce adverse
23:23cardiovascular events and which did not
23:27materialize for many of these trials.
23:30Often due to the ways the studies
23:33were designed or powered, however,
23:35this trial out of Sweden which focused
23:39specifically on women who survived an
23:42acute myocardial infarction or underwent
23:45a major coronary revascularization.
23:48They offered these women a program where
23:53the focus was on psychoeducation stress
23:57reduction through relaxation training,
23:59self monitoring,
24:01cognitive restructuring and to
24:03realize a more adaptive coping skill
24:06set when they were dealing with
24:09family and work related stressors.
24:11Ends simultaneously also focus on self care
24:14and compliance with the medical regimen,
24:17and so this trial did show a significant
24:20survival effect that was actually
24:22threefold in comparison with the
24:25usual care for long term mortality.
24:28So so these are some of the critical
24:32trials that were conducted,
24:36and our colleague Matthew Berg,
24:39Dr Burke,
24:39was also one of the key pioneers
24:41of many of those.
24:42Interventions that were tested
24:45in coronary artery populations,
24:48so all of these developments in
24:52the cardiovascular population gave
24:54rise to what we now today referred
24:57to as cardiac psychology,
24:59and it was described in in these works.
25:02That that this is really a
25:05subspecialization of health psychology.
25:07And, as I mentioned,
25:08colleague Doctor Matthew Burke
25:10being one of the lead figures of
25:13this subspecialization The EPA also
25:15recognizes this term of cardiac psychology,
25:19although it it does label it as
25:22an emerging subspecialty.
25:24So it's still very much under development.
25:29So in what comes next?
25:32I want to make the case that.
25:34Hard mind and vascular really are so
25:36intertwined that we should be looking
25:38at the spectrum of cardiovascular
25:40diseases and also when we think
25:42about psychosocial factors and keep
25:44that whole entire spectrum in mind.
25:47And it also highlights the
25:49need for further support.
25:51Specialization and expansion.
25:52Early insights in in these populations
25:55and our treatment models and how we
25:57translate them to clinical care.
26:01As you all know, atherosclerosis is a
26:05generalized disease and significant
26:07atherothrombotic events may manifest
26:10in different arteries of the body.
26:14It may happen in in your carotid
26:16artery in in lower extremity arteries,
26:18and much of our work has focused on
26:21on that lower extremity population,
26:23peripheral artery disease,
26:24or PAD as one refers to.
26:27And it is often still a very
26:31underrecognized condition,
26:31for which there is great unawareness
26:34and also under treatment.
26:35And what we see is that the
26:38cardiovascular event rates are
26:40often worse than as we see for
26:43coronary populations because.
26:44That field has progressed so much
26:47further and risk management and
26:49and recognition and population
26:51awareness as opposed to other.
26:54Atherothrombotic diseases on
26:55the cardiovascular spectrum.
26:59Before I highlight on PED,
27:01I also want to make a mention
27:04of the REACH registry,
27:06which was another big global study,
27:09a landmark study that studied the spectrum
27:13of atherosclerosis in a global setting.
27:17And the strength of that study was that
27:20it it focused on coronary artery disease,
27:23peripheral artery disease,
27:24and cerebrovascular disease,
27:25but really demonstrated that these are
27:28manifestations of the same process.
27:31Many people have overlapping disease,
27:33and it also contrasted some of the
27:37differences in outcomes and under
27:39treatment for these conditions.
27:42So there was also a cohort of PD patients,
27:44and as you see there is much overlap
27:47with coronary artery disease as
27:48well as cerebrovascular disease.
27:50So patients may never present
27:52with with an isolated condition.
27:54There's always that broader conglomerate
27:56of risk that we need to be in mind,
28:00and it depends on where the
28:03atherothrombotic events manifest
28:05first as to what you're presenting.
28:09Complaint is and how you entered
28:11the system for cardiovascular care.
28:17So the PD disease burden to give you
28:21an idea when people present with PD is
28:24it's often a marker of very aggressive
28:28generalized atherosclerotic disease.
28:30And resulting in in reduced what
28:33filling their leg arteries and over 200
28:37million people are affected globally.
28:39And in the US alone,
28:41we have a population of over 8,000,000,
28:45and so it's on the rise in both high income
28:47and low income and middle income countries.
28:49Both men and women.
28:51And it's rapidly growing due to the
28:53aging population and steady increase in
28:56obesity and diabetes rates and and so
28:58it's a serious public health problem.
29:02Katie can present as a
29:05spectrum of manifestations.
29:07There's people who don't know
29:09they have it but and are labeled
29:12as asymptomatic when they do
29:15undergo noninvasive testing.
29:17They might see that there's
29:18reduced Platt flow,
29:19but do not present with active symptoms.
29:23And often that is because
29:26of a sedentary lifestyle.
29:28But these patients are also at
29:30risk of having adverse outcomes
29:32and then further down the spectrum.
29:35There are symptomatic manifestations,
29:37pain while walking that has a different.
29:41Gradations of severity and then
29:43towards the end we have critical limb
29:46ischemia manifestations where the
29:48limb is really in danger and people
29:51are dealing with non healing wounds,
29:54wounds and a high risk of amputation.
29:57So people if patients present with PD
30:00in spite of optimal medical management,
30:04the residual risk for major adverse
30:07cardiovascular events and live
30:09events is about 5 to 10% per year,
30:11which is pretty high.
30:13If we look at critical limits,
30:14chemia one in five has does not
30:19survive at 6 to months to a year
30:22and about half of the patients
30:24would seali does not survive.
30:27At five years.
30:28It is also very costly and most
30:31of the expenditures are incurred
30:33for people's inpatient care,
30:35which often consists of a lot of repeat
30:41revascularizations and complicated stays.
30:44Same risk factors as the
30:46coronary artery disease.
30:48However,
30:48smoking,
30:49obesity,
30:49and aging are one of the more
30:54prominent ones as well as
30:56diabetes and a lot of people with
31:00this condition also develop.
31:02Chronic kidney disease.
31:04And so the disease profile
31:07is fairly complex.
31:10So despite the magnitude of the
31:12problem and the role of lifestyle
31:14factors also for this condition,
31:16there's only been recent interest
31:18that there has been a focus on studies
31:21psychosocial factors in this condition,
31:23with most of the work highlighting
31:26the role of depression and in this
31:28illustrating that the prevalence really
31:30is very similar to the ones reported
31:33in coronary artery disease populations,
31:35both in stable populations as well
31:37as in people undergoing procedures,
31:39as demonstrated. Year across these cohorts.
31:45Also concerning is that in the US
31:48this is a sample that we studied a
31:52national sample of inpatient admissions.
31:55Where we see a rise in those admissions over
31:59the last decade for critical limits chemia,
32:02the most severe manifestation.
32:04And what we see is that the most rapid
32:08increase in those admissions take
32:10place in populations younger than 65.
32:14You see the squares here representing
32:17men below 65, and then also rapid
32:21uptake in women of below 65 years,
32:23which is very typical of how we know it,
32:27because typically it is disease
32:30presents in older populations.
32:32And then with those admissions,
32:34one in five admissions is characterized with
32:37a comorbid anxiety and depression diagnosis,
32:40and these are recognized diagnosis.
32:42So possibly only representing
32:44the tip of the iceberg.
32:46But here we also see a steady
32:49increase over time in the last
32:52decade for both PD and and CLI.
32:54Which may be related to the younger
32:57population that is is affected by
33:00these admissions or better recognition,
33:02or a true greater prevalence,
33:04and that we don't know.
33:07And if we zoom in on the risk
33:09profile of these patients,
33:11we see that underrepresented minorities.
33:15People without insurance are more likely
33:18to represent it in the younger group,
33:21and they also present with lower
33:24household income, more diabetes.
33:28Obesity prior amputation,
33:30addiction and mood disorders,
33:33and this is a profile that we
33:35really don't see as much reoccurring
33:38in the older populations.
33:42Recognize depression in patients
33:44with Celine during an admission
33:46is also associated with a higher
33:49odds of undergoing and imputation,
33:51both for endovascular procedures
33:53presented here on the left and
33:56surgical revascularization.
33:58And so whether this is
33:59constantly related or not,
34:00the fact is that people who
34:03who go through this experience
34:05are much more likely to also
34:07copresent with a major depression.
34:10Depression.
34:13In this same cohort,
34:15we demonstrated that having
34:18comorbid depression translated
34:20into a longer length of stay,
34:22both for endovascular procedures
34:23as well as surgical procedures,
34:25and it also results in higher
34:28total charges for their states are
34:31really it is a group that warns
34:34more care and has is at risk of
34:37more complex disease outcomes.
34:43When we pull all the work done in PD
34:46together on the risk factor of depression,
34:48which we recently did with this
34:50meta analysis in our group,
34:52we see a definite trend emerging for
34:55an association between depression and
34:57mortality as we see in the top panel for
35:00major adverse live events and amputation.
35:02Unfortunately, there is still a possibility
35:04of data out there to show that link,
35:07but we do see announcing a nonsignificant
35:10trend towards higher risk emerging.
35:15Making a switch now to the portrait
35:17registry work that we have done
35:20where we followed people with a new
35:22diagnosis of PTSD and who presented at
35:25vascular clinics and sought out care
35:28at their vascular specialty clinic in
35:31the US and Netherlands and Australia.
35:34So we see that 35% either presents with a
35:39positive screen on depressive symptoms,
35:41anxiety, or perceived stress upon arrival.
35:45And a year following one in five
35:48unique patients still score high on
35:51either one of those questionnaires
35:53for those depressive symptoms,
35:56anxiety and perceived stress.
35:59So people do.
36:00Report these symptoms as they navigate
36:03their care and zooming in on the
36:06experience of stress for this population.
36:09When people report increase scores
36:11for perceived stress at 2 subsequent
36:14times as they are navigating their
36:17care within that study, we.
36:20Linked that with their long term
36:22survival and what we see is that
36:25in the four year subsequent to
36:27receiving care for PD,
36:28those who reported the
36:29highest trust experiences.
36:30They also have much higher.
36:34Mortality rates over the long
36:38term observation period.
36:40Same what we see in the disease,
36:43specific health status and
36:46trajectory of these patients.
36:48People in blue are the ones who
36:51represent those with chronic stress
36:54experiences and their health status
36:56scores are mapped out over the
36:58year of their treatment and what
37:01we see is that the differences
37:03accomplished between distressed
37:04and non distressed populations is
37:06exceeding 3 times the minimally
37:08clinically important difference.
37:10Overdose health status outcomes.
37:12So really very impactful and detrimental
37:15to their PD rehabilitation trajectory.
37:21We then further looked at two
37:23who was experiencing these
37:25chronic stress experiences,
37:26and we found that these chronic stress
37:30experiences can be reliably predicted.
37:33We assessed their stress at baseline 1/6
37:36and 12 month follow up and we did that
37:40in acute myocardial infarction cohort,
37:43which was our derivation cohort
37:45for developing this model and we
37:48validated our model in the PD
37:50cohort that I just described.
37:52And again, chronic stress was
37:54defined as A at least two follow-up
37:58assessment periods with exceeding
38:01scores above the population norms.
38:05Factors that explain people's chronic stress,
38:08experiences and the predictive
38:11probability was 77% for the model
38:14that we developed and younger age
38:17female sex and socioeconomic factors.
38:21Economic hardship in particular,
38:23access to care barriers and low social
38:26support really explained why people of
38:29course were experiencing this chronic stress.
38:32Knowing that this population
38:34is so much affected by it,
38:36this is important treatment information
38:39to integrate as people get offered
38:44expensive procedures and and complicated
38:47disease management trajectories.
38:51And then lastly I want to highlight how
38:54depression and stress in PD populations may
38:57relate to their physical activity levels,
38:59and that's that concludes the portrait
39:03data that I wanted to highlight.
39:06The cornerstone of PD management at class.
39:09One recommendation is that people
39:11get off for walking therapy and they
39:14are encouraged to walk three times
39:16a week for at least 30 minutes.
39:18To stimulate their cardiovascular
39:20fitness and growth of collaterals.
39:22To improve the provision in their legs.
39:25In portrait, we had the depression,
39:27perceived stress,
39:28repeated assessments available,
39:30but we also had repeated assessments
39:33for physical activity and we took
39:36the same questions as were done
39:38for the inter heart study.
39:40The global study where we could
39:43rank people as sedentary,
39:45engaged in wild activity
39:48or strenuous exercise.
39:51And here are the levels of depression
39:53and stress in those line graphs and
39:56then the bar charts really present
39:59the sedentary behavior levels and you
40:01can see that this is very high upon
40:05presentation with a new diagnosis,
40:0744% of reports being sedentary at baseline.
40:11And even though those levels
40:12go down over time,
40:13they still remain pretty high.
40:17And when we tried to reconstruct the
40:21causal pathways of stress and physical
40:23activity in PV with generalized
40:26structural equation modeling,
40:27we see that stress at the
40:30top here and lowered physical
40:32activity reinforce each other,
40:35and we see bidirectional relations emerge,
40:39meaning that a decrease in physical
40:41activity results in higher stress
40:43experiences and higher stress
40:45experiences result in decreased.
40:47Physical activity which is a
40:50problem for the management of
40:52of these patients and disease.
40:55For the pression,
40:56we see a slightly different picture,
40:58and as you can see the
41:01following strong trends emerged.
41:03Patients who lower their level of physical
41:08activity at baseline or then result.
41:11Subsequently they present with
41:14higher levels of depression and
41:16these effects are reinforced further
41:19downstream of the PD rehab trajectory.
41:22Underscoring that.
41:23Again,
41:23the role of physical activity and the
41:27risk of depression go hand in hand and.
41:31Need to be seen together as
41:34as one manages this disease.
41:37So the key takeaways from this line
41:40of research are, not surprisingly,
41:42that depression and perceived stress
41:44are very common in PD that PD and
41:47overall is on the rise with increasingly
41:50complex patient profiles and people
41:53presenting with more severe disease
41:56and a rapid growth in younger populations.
41:59Number two,
42:00what I like to highlight is that it is
42:03associated with increased mortality,
42:05poor PD, health status,
42:07recovery trajectories,
42:08higher cost and longer admissions and #3.
42:12We do know who is at risk
42:14of high stress experiences,
42:15and we also know that it is.
42:19Very much intertwined with people's
42:21levels of physical activity,
42:23which is part of of the cornerstone
42:27of PD management,
42:28behavioral activation and and.
42:31Physical activity to achieve successful
42:35outcomes and stress and depression
42:39may exacerbate the cycle of of
42:42sedentary behavior in this population.
42:48So in the final part of my presentation,
42:52I would like to make the case for
42:54how integrated care options for
42:56cardiovascular populations and
42:58specialty care are needed to come
43:01to a more value based care delivery.
43:03So, as I highlighted throughout my talk,
43:06atherosclerotic disease is a
43:08generalized process and manifestations
43:11can occur in the coronary,
43:13carotid and lower extremity arteries.
43:15And even though the interest in the
43:18field started in coronary disease
43:21because those manifestations were
43:23probably also more dramatic and and,
43:26and that's where everything started.
43:29I feel like we're just at the beginning of
43:32documenting and understanding the impacts
43:34of other manifestations on people's lives.
43:36I haven't even covered
43:38carotid artery stenosis,
43:39which is another unique set of symptoms
43:44and care interactions that need to
43:48be considered for those populations.
43:52So really it makes sense to.
43:55Start broadening the subspecialty
43:57of cardiac psychology and and
43:59to include vascular populations.
44:02Because it's really a spectrum of disease.
44:05And recently we came together with a
44:08few colleagues here at Yale colleagues,
44:11psychologist and cardiologist were we.
44:16Reflected on the role of what cardiovascular
44:19psychology or health psychology could
44:22contribute to cardiovascular care.
44:25There is a, of course,
44:26a role for intervention,
44:28design,
44:29delivery and testing,
44:30and there's a role to address
44:33psychosocial behavioral factors
44:35to promote lifestyle changes that
44:37we often recommend these patients
44:40to make and the support that they
44:43need to help make these changes.
44:46And the impact on their health outcomes.
44:49Health psychology can contribute
44:50to the assessment and the design
44:53and the analysis and interpretation
44:55of psychosocial risk factors,
44:57both at the patient level,
44:59but also measures at the programmatic level.
45:02As a lot of of the fields in in
45:04in medical specialties and in
45:07behavioral healthcare are moving
45:09into measurement based care.
45:11Where we let patients.
45:17Say what quality of care means and and
45:20and how that is reflected in the scores
45:24on on these domains of assessment.
45:27Treating comorbid mental mental health
45:29disorders in the context of medical
45:32illness and facilitate patient care team
45:35relationships and provide insight and.
45:38Expertise and the role of psychology
45:41for physiological interactions that take
45:44place within cardiovascular diseases.
45:46And understanding how it affects the
45:49patients experience and in the last
45:51decade a lot of the treatments for
45:54coronary and cardiovascular disease
45:56in general has gotten increasingly
45:59more technical and with a lot of
46:02technological innovations taking place.
46:03So it's also important to consider what
46:06treatment options are available and
46:08how that impacts the disease process
46:10and the role of psychosocial factors.
46:13And so there too is a role for cardiac.
46:16Would carry a vascular sychology.
46:20So for integrated PED care it is
46:23not only what are the patient wants
46:25stents or or what are surgical
46:28bypass is the right way to go,
46:30or supervised exercise is
46:31something that people might want
46:33to try and the medications to
46:36lower their cardiovascular risk.
46:38But it is also do people have the
46:41support and the capacity to navigate all
46:45of these disease experiences and the
46:47interaction with their treatment and.
46:49Is their care being addressed
46:52from a whole person perspective
46:54and or psychosocial factors also
46:57considered for the disease management?
47:01So increasingly our teams become
47:04multidisciplinary and models of
47:06Co treatment and cross training
47:08actually make sense if we want
47:11to meet the patient's needs.
47:13And as specialties move in and out
47:16the circle depending on on the
47:18different needs and we feel that.
47:20There is definitely a place also
47:22for health psychology to help
47:25support the specialty care of
47:27these populations as they manage
47:29their cardiovascular condition.
47:34Many of of the goals for managing a
47:36depression or managing stress and managing
47:39peripheral artery disease as discussed,
47:42overlap, and so increasingly an
47:45interdisciplinary team based approach
47:47makes sense to to realize more
47:50successful outcomes in this population.
47:56Collaborative work and care has been
47:59shown to be effective for medical
48:02populations such as diabetes.
48:04Oftentimes, these models were offered
48:06offered in the primary care setting,
48:09and so there is a model for success
48:12that has been demonstrated.
48:14But with the increasingly complex
48:17populations and the intensity of
48:19care that people undergo and complex
48:23interactions with their treatments.
48:25There's a case to make to offer behavioral
48:27health care within the specialty setting,
48:30as it also is perhaps desired from
48:33the patient's perspective and from a
48:36referral and care linkage perspective.
48:38Being part of the same treatment
48:40team is is something to strive for.
48:46We're finding ourselves at a new juncture.
48:49Is is what I feel.
48:52We described the post war chronic
48:55disease burden, but we're still
48:57dealing with that disease burden.
48:59And as you look at the
49:02global burden of disease,
49:04ischemic heart disease tops this list
49:08in both populations 50 + 75 years
49:11and plus or populations age rapidly.
49:14And the demands on our health services
49:17and healthcare systems continue to
49:19increase and so this is something really.
49:22Policy makers and healthcare
49:25administrators need to integrate
49:28in their policy and and the way we
49:32deliver and design care for patients
49:34and how that care is value based and
49:37and it is a good return on investment.
49:40So there's still an enormous wave of of
49:42new challenges for the sustainability of
49:45our healthcare systems that is coming.
49:47Towards us.
49:50So we found ourselves at a such a
49:52junction before as I explained in
49:54the beginning of my presentation,
49:56but today's reality adds a little
49:58bit more complexities into the mix,
50:00so I gains in prevention for
50:04cardiovascular disease.
50:05Seem to need to be reinvigorated.
50:07Given that younger populations present
50:09earlier with much more aggressive
50:12disease due to lifestyle factors.
50:14Cost are really unsustainable.
50:17There's highly technological care
50:19being incentivized over basic high
50:22value care and the people who have
50:24access to that highly technological
50:27care versus those who don't.
50:30Those disparities continue to increase,
50:33and there's an enormous burden
50:36towards vulnerable populations who
50:38even have difficulties accessing
50:40care and are being diagnosed early.
50:43And so it does show up late in the
50:46disease process with more complex disease,
50:49and we see decreasing life expectancy
50:53in younger generations because of that.
50:56And and then we face the post
50:58pandemic and and global challenges,
51:01which really has increased the mental
51:04health burden overall and strain
51:07communities that are suffering.
51:09So health psychology can yet again
51:12provide an answer to these complexities
51:15and how to deal with this reality
51:17and contribute to more value based
51:20care models that can address medical
51:23populations from a whole person.
51:27Perspective and offer our expertise in
51:30in the chronic disease trajectories.
51:36I would like to thank all of the
51:40faculty collaborators here at
51:42Yale and outside and and globally.
51:44Also, who have contributed to
51:46this work and the people in our
51:49research team and here at Yale,
51:51but also at the America Heart Institute.
51:54In Kansas City and the team in in Tillburg,
51:58and of course all the patients
52:01that have contributed to this
52:03data of of this body of work.
52:06And I want to thank you for
52:08listening to my talk and having me
52:10in this grand Round series and also
52:12would like to encourage people to
52:14join our upcoming health Ecology
52:17Virtual Forum happening May 20.
52:20Where the growth and contributions of
52:22health psychology will be further discussed,
52:24and I'd be glad to take any questions
52:26and thank you for listening.