Integrating Behavioral Health Into Heart Care for a Healthier Heart: A Q&A with Matthew Burg, PhD

Matthew M. Burg, PhD, professor of medicine (cardiovascular medicine), has spent much of his career investigating how stress and psychological experiences contribute to heart disease and heart disease outcomes. Burg, a clinical psychologist, was recently elected president of the Academy of Behavioral Medicine Research, an organization of scholars elected by their peers in recognition of their work to advance the broad field of behavioral health.

We spoke with Burg about his presidency, recent research, and aspirations for better integrating behavioral and psychological health into cardiovascular medicine.

To be elected president of the Academy by my peers is an incredible honor.

I believe my election is not just a recognition of my research but also an acknowledgment that we can do more to contribute to external conversations to help improve public health. For the past few years, I have been urging my colleagues in the academy to speak out and comment on issues related to public health. As behavioral health experts, we have the knowledge and responsibility to share what we know to help prevent disease and improve the health of our population.

More than half of the chronic disease burden can be attributed to lifestyle behavior, and the conditions under which people live. To address the burden of chronic disease, we need to do more to incorporate psychological and behavioral health, a field called behavioral medicine, into public health.

We know that behavioral and psychological health are critical for patient well-being. Some studies show that integrating behavioral medicine into medical care improves patient outcomes, enhances patient satisfaction, and reduces health care utilization.

For example, studies have found that addressing depression in a patient with chronic disease will improve their blood pressure, lipid levels, and so on. Those changes are probably because the patient is now engaging in a healthier lifestyle and taking their medications.

Yale has been making progress in this effort. We’ve now brought on Kim Smolderen, PhD, and Allison Gaffey, PhD, both clinical psychologists, who conduct research and see patients. I’m hopeful we will continue integrating behavioral and psychological health into clinical care.

We know there is a clear relationship between psychological experiences and the heart, but we're still learning about the direct effects of negative emotions on the cardiovascular system.

I recently co-authored a study examining how negative emotions affect endothelial function, which is a very early risk biomarker for heart disease. In a healthy person, the endothelium will dilate and constrict based on the metabolic needs of different areas of the body. In our study of healthy people, we discovered that merely telling a story that made you angry or anxious can damage your endothelial cells. This damage or death to endothelial cells could lead to coronary artery disease.

Our study provides further evidence that negative emotions and stress have very real, biological effects that are part of the heart disease trajectory.

Yes, in other publications, we showed that a simple stress reduction intervention eliminated this response.

We tested a centering intervention, where we asked a person to think about what they truly value. Then, when we asked them to think about a situation that made them feel stressed or angry, those emotions no longer had the same negative effect on endothelial function.

This was one small study with just a small number of participants, but it shows the promise of these interventions. If you scale it up and focus on people at high risk of major cardiac events, you could make an enormous difference in patient outcomes.

One challenge is reimbursement models. Medicare, Medicaid, and private insurance companies provide meager reimbursement for psychological services. Changing culture is hard, especially in health care, where many people and entities are involved in caring for patients, both in inpatient and outpatient care settings.

Another significant challenge is that we don’t have models of care to refer to. My goal is to test models of delivering integrated cardiovascular care where we address depression, anxiety, loneliness, stress, and lifestyle behaviors to help prevent and slow the development of heart disease.

Behavioral health research needs to move into the clinical space to implement some of these interventions earlier in the research process. We also need to consider a wide range of outcomes like patient satisfaction, unnecessary utilization of care, and patient participation in their own care.

If we show an improvement in these outcomes, my hope is that it will inspire others to change payment models and culture and address other obstacles.

The Department of Internal Medicine at Yale School of Medicine is among the nation's premier departments, bringing together an elite cadre of clinicians, investigators, educators, and staff in one of the world's top medical schools. To learn more, visit Internal Medicine.

Spicer J, Shimbo D, Johnston N, Harlapur M, Purdie-Vaughns V, Cook J, Fu J, Burg MM, Wager TD. Prevention of Stress-Provoked Endothelial Injury by Values Affirmation: a Proof of Principle Study. Ann Behav Med. 2016 Jun;50(3):471-9. doi: 10.1007/s12160-015-9756-6. PMID: 26608279; PMCID: PMC5087990.