Programs using remote delivery of mental health interventions and promotion of psychological well-being are set to play an increasingly important role in supporting cardiovascular health.
Collaborative care and other integrated care models have customarily been used successfully to manage psychiatric disorders, such as depression, in patients with heart disease. They have had beneficial effects on function and other outcomes.
But new “blended” care programs, including mobile treatment delivered remotely, are set to achieve even better results, say researchers Jeff Huffman, MD, FAPM, Caitlin Adams, MD, and Christopher Celano, MD, FAPM, from the Department of Psychiatry at the Massachusetts General Hospital and Harvard Medical School, Boston, in the January/February edition of Psychosomatics.
“Standard integrated care models are effective at improving mood, anxiety and function in patients with heart disease,” they say. “Novel, ‘blended’ collaborative care models may have even greater promise in improving cardiac outcomes.”
The new approach interfaces with cardiac patients via mobile applications, text messages, and video visits; it uses stress management, mindfulness, and positive psychology techniques.
The researchers point out that cardiovascular disease is a leading cause of mortality worldwide, responsible for 8 million deaths each year. Approximately, 15% of patients with stable heart disease have current major depression, a rate that is substantially higher than in the general population or primary care medical settings.
This elevated rate of major depression also applies to patients with more serious cardiac conditions, including acute coronary syndrome (myocardial infarction or unstable angina), heart failure, those undergoing cardiac surgery, and those with implanted cardioverter defibrillators.
Among those with acute heart disease, depression is typically a chronic condition that precedes an event and persists for a prolonged period. Without treatment, such symptoms usually do not resolve.
Depression is also associated with the development and progression of heart disease. In individuals without pre-established heart disease, depression is linked to the onset of coronary artery disease (CAD). Those who experience depression earlier in their lives have higher rates of CAD and cardiac mortality, independent of traditional risk factors and a family history of heart disease. Depressive symptoms are associated with a 60% increased relative risk of developing CAD, compared to those without such symptoms.
Depression also is linked with CAD progression in those patients with stable heart disease, as depression is independently and prospectively associated with elevated rates of major cardiac events, independent of sociodemographic factors, initial CAD severity, medical comorbidity, or other factors.
Depression is also associated with increased mortality in patients with more acute or serious cardiac illness. Following an MI, cardiac surgery, or another major cardiac event, or among those with heart failure, depressed individuals have substantially greater rates of mortality compared to people who are not depressed. More than 50 studies have linked post-ACS depression with adverse medical outcomes, leading the American Heart Association to identify depression as a risk factor for poor cardiac prognosis following an ACS, signaling increased awareness in the cardiology community of the adverse effects of depression.
Discovering effective treatment for depression and anxiety disorders in patients with heart disease has been a challenge, say the researchers. “Evidence-based psychotherapy interventions, such as cognitive-behavioral therapy, have largely had beneficial effects on depressive symptoms among patients with heart disease, and they can be individualized for each patient based on their specific needs. However, in formal trials among heart disease patients, these interventions have led to limited or no improvements in objective medical outcomes (such as hospitalizations or mortality).”
Furthermore, well-trained therapists who can deliver evidence-based treatment are difficult to access in clinical settings, especially in rural areas. Yet effective depression treatment requires frequent monitoring and stepped care with dose adjustments.
Collaborative care and related integrated care models may represent an important departure from prior models in terms of managing larger numbers of patients, say the researchers. These models use a non-physician care manager to identify depression, or other psychiatric conditions, obtain recommendations from a team psychiatrist, and convey these recommendations to the patient and his or her primary medical provider, who prescribes all medication. The care manager then follows patients, providing ongoing assessment and therapeutic interventions, monitoring treatment response, and coordinating care between the supervising psychiatrist and primary medical provider.
Collaborative care has also been studied in patients with heart disease. It has been associated with significantly greater improvements in mental health-related quality of life, depression, and function. Although there have been no differences in hospital readmission rates, the intervention has been associated with lower overall estimated median costs over a 12-month period.
Trials of phone-based integrated care (problem-solving therapy via telephone or in person, pharmacotherapy, both, or neither, stepped every eight weeks) show, after a six-month intervention, greater depression improvements and lower rates of major adverse cardiac events, compared to contemporary treatment alone.
As a result of such findings, modifications have been designed to more fully address health behaviors and medical outcomes through a ‘blended collaborative care’ model.
Nurse care managers use a ‘treat-to-target’ approach for not only depression but also medication adherence and disease parameters (e.g., blood pressure). They focus on depression symptoms and treatment, use motivational interviewing to prompt health behavior change, and inquire about disease self-monitoring (e.g., self-monitored blood pressure or blood glucose) and medication adherence – enabling the care manager to take a much more holistic approach to patient care management rather than a “silo approach” to symptoms.
The care manager has medical specialists (e.g., diabetologists, cardiologists) as part of the care team, in addition to the psychiatrist, to provide support, recommendations and guidance.
In a 12-month randomized trial of 214 patients with poorly-controlled diabetes, coronary heart disease, or both, and co-existing depression, the “blended” approach was associated with significantly greater improvement in depression. “Furthermore, unlike standard collaborative care trials, the intervention was associated with greater improvements in hemoglobin A1c, systolic blood pressure, and LDL cholesterol, suggesting that this multi-pronged approach has substantially greater effects on key medical outcomes,” say the researchers. “Patients in the intervention group were also more likely to have had an adjustment in insulin, antihypertensive medications, and antidepressant medications, and they reported better overall quality of life.”
The “blended” model was further tested in 18 health centers and 172 clinics in eight US states with patients with diabetes mellitus or CAD, who had poorly controlled glucose or blood pressure, along with co-existing depression. Outcomes were:
“These seemingly modest goals, if achieved in these complex patients, could eventually lead to savings of hundreds of thousands of dollars, with substantially reduced risk of many major medical events, and possibly lower rates of mortality, when viewed from a population health lens,” say the researchers.
Moreover, mobile interventions appear popular with patients. Currently, 95% of American adults (including 97% of 50-64 year olds) own a cellular phone, and half of smartphone owners have downloaded at least one app related to health, suggesting people are eager to use mobile devices to manage their health. Collaborative care management programs could make use of mobile-health tools to treat participants, wherever they are. “Such automated programs are often low-cost, very low-burden for patients and providers, and match patients’ desire to use remote tools for health purposes,” say the researchers.
Mobile apps, text messages, video virtual visits with patients… all are growing in popularity and confer at least some of the benefits of in-person sessions with a far-reduced burden on both patients and providers compared to meeting in a shared location. “It seems clear that these modalities will be a key part of next-wave collaborative models in the years to come.”
Guides for implementing collaborative care models have been developed by the University of Washington’s Advancing Integrated Mental Health Solutions Center: