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Experts offer tips for psychiatrists who treat patients with heart disease

Psychiatric care for patients with heart disease should focus on the affective, behavioral and cognitive factors and interventions to improve both the mental and physical health of patients, according to a CME article published in Psychiatric Annals.

Heart disease affects tens of millions of adults in the U.S. and is one of the most common causes of death. The condition often coexists with psychiatric illness; therefore, it’s vital to better understand its pathophysiology and treatment to provide the best psychiatric care, according to Daniel J. Daunis Jr., MD, and Theodore A. Stern, MD, of Massachusetts General Hospital.

In their article, Daunis and Stern discussed how heart disease affects the psychiatric care and treatment of patients as well as treatment strategies to improve overall health to serve as a guide for psychiatric clinicians.

Affective considerations

Affective symptoms usually involve anxiety and depression, the authors explained.

“One approach to care for people with heart disease revolves around the diagnosis and treatment of both the affective consequences of heart disease and comorbid affective illness,” they wrote.

Daunis and Stern recommended that when evaluating a patient for affective symptoms, clinicians should focus on associated symptoms, such as chest pain, palpitations, shortness of breath and/or disorientation. During routine psychiatric care of patients with heart disease, clinicians should:

• perform comprehensive review of systems;
• review basic vital signs (ie, heart rate, pulse oximetry and blood pressure); and
• conduct routine physical examination (paying attention to pulmonary, cardiovascular and neurologic systems).

“Once underlying acute medical processes are ruled out or addressed, psychiatric care of affective symptom domains focuses largely on either treatment of underlying primary psychiatric illnesses or psychiatric symptoms associated with chronic medical illness,” Daunis and Stern wrote.

Anxiety is frequently reported in those with heart disease; therefore, diagnosing and treating anxiety disorders is important for the overall quality of life in patients with heart disease, the authors wrote. Before starting treatment for depression in patients with heart disease, they recommended that clinicians review the effects of medications (like selective serotonin reuptake inhibitors) on the QTc interval, blood pressure and coagulation profile.

Behavioral considerations

Daunis and Stern also advised that psychiatric clinicians focus on evaluating and treating health behaviors related to heart disease when caring for patients, such as smoking, diet and exercise.

“Psychiatrists, given their specialized understanding and treatment of human behavior, are uniquely positioned to address certain unhealthy behaviors,” they explained.

In addition to treating patients with nicotine-replacement therapies and medications to reduce cravings, clinicians can get patients to record their smoking habits to help them identify specific smoking cues or triggers and suggest patients try cognitive behavioral therapy or mindfulness techniques, the authors wrote. Regular exercise is important to prevent heart disease, and psychiatrists can help patients by reviewing exercise journals and identifying possible barriers or using the five-step cycle to help patients implement healthy habits.

Cognitive considerations

Lastly, psychiatrists should consider cognition when caring for patients with heart disease, according to Daunis and Stern.

“Patients with heart disease are predisposed to strokes, which can directly influence cognitive functions, specifically executive function, motivation and health behaviors,” they wrote. “Patients with heart disease are also more susceptible to delirium, which is associated with poorer outcomes, longer ICU stays and overall increased mortality.”

Psychiatric clinicians can help identify cognitive deficits in patients using screens like the Montreal Cognitive Assessment or the Mini-Mental State Examination to better detect deficits in specific cognitive domains that influence behaviors, like medication adherence, the experts explained. – by Savannah Demko

Disclosure: Stern reports salary from the Academy of Consultation-Liaison Psychiatry and royalties from the MGH Psychiatry Academy.