On any given day, clinical psychologist Melisa Chelf Sirbu, PhD, might teach a class on “banishing the blues,” help a patient quit smoking or chat with a client while he’s on the treadmill — maybe about the latest football scores.
“I do a lot of therapy while they’re in their exercise sessions,” says the cardiac rehab psychologist at Charleston Area Medical Center in West Virginia. “They might not want to meet with me in my office, but they’re glad to talk about whatever’s going on while they’re working out.”
This flexible, patient-friendly approach typifies the world of cardiac rehab psychologists, whose patients include some of the 27 million Americans who have heart disease. Many of these patients also have other psychological and behavioral problems and have never before seen a mental health professional.
And research suggests that psychological interventions work for these patients. A meta-analysis of 51 psychological interventions for heart disease in the May American Journal of Epidemiology (Vol. 169, No. 9) found that as a whole, psychological interventions help to reduce clients’ total cholesterol and anxiety. Psychological interventions that include behavioral components help to reduce the chance of heart attack and death from any cause, and those with behavioral or cognitive components may help to ameliorate symptoms of depression.
That research, by British biostatistician Nicky J. Welton, PhD, and colleagues, echoes what psychologists and others have reported since the 1970s: Psychological factors affect heart health. Specifically, many studies have found that depression, stress, anxiety, anger, hostility and social isolation contribute to the development and exacerbation of heart disease, independent of other factors, such as medical status and lifestyle.
Even so, there’s still a large gap between research and practice in the area, mostly because few psychologists work on staff or even consult to rehab programs. That’s because programs tend to be primarily exercise-based, says James A. Blumenthal, PhD, a Duke University researcher who develops and tests stress-management interventions for heart patients.
“At most rehab programs, you may see a nutritionist for several sessions and maybe get a lecture on stress or the psychological aspects of coronary disease,” he says. “But programs don’t tend to integrate comprehensive stress-management training into their services.”
What’s more, it’s challenging for non-staff psychologists to get reimbursed, and there is a general lack of knowledge in the psychology profession about this important niche, says cardiac rehab expert Kent Eichenauer, PsyD, who practices in Urbana, Ohio. “Yet psychologists are in a unique position to connect with heart patients in these programs during one of the most vulnerable times in their lives,” he says.
And cardiac rehab programs are hungry for psychologists’ services, suggests an unpublished survey of 309 cardiac rehab programs across the country, conducted by U.S. Department of Veterans Affairs psychologist and cardiac rehab specialist Jennifer Cameron, PhD, and Bonnie Sanderson, PhD, a nursing professor at Auburn University. The survey found that only 3 percent of cardiac rehab programs had a mental health professional on staff and only 4 percent had contracts with mental health providers. At the same time, 80 percent of directors said psychosocial assessment is important.
“The reality is that everyone would love to have a psychologist or mental health professional on site,” Sanderson says.
That may now be more likely to happen, thanks to several developments. For one, the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) are calling for all cardiac rehab programs to assess patients’ psychological risk factors as part of their evidence-based measures. In addition, AACVPR has formed a Behavioral Health Liaison Committee to link qualified mental health providers with cardiac programs to improve the services they offer, says Eichenauer, a committee member.
“The committee is a major step forward in AACVPR’s commitment to helping heart patients with psychological risk factors,” he says. “While programs often screen patients for psychological problems, they’re not necessarily equipped to treat them and they generally don’t have specialists they can refer people to. With this new committee, we’ll be able to help programs access appropriate psychological care for their patients.”
Reimbursement for psychologists who practice in the area is also changing: The most recent health and behavior Current Procedural Terminology (CPT) codes should allow psychologists to bill more easily for these services.
A new study may further boost psychologists’ integration in this area. A trial headed by Blumenthal and funded by the National Institutes of Health will randomize 150 cardiac patients to 12 weeks of either standard cardiac rehab, or to cardiac rehab enhanced by a stress-management intervention. Over four years, the team will examine participants’ quality of life, biological markers of heart disease and clinical events, including heart attacks, bypass surgery and death. The study follows earlier research reported in the American Journal of Cardiology (Vol. 89, No. 2) and the Journal of the American Medical Association (Vol. 293, No. 13), which found that a stress-management intervention that includes group support, psychoeducation and coping skills training produced better outcomes and was less costly over the long term than usual care or even exercise, the mainstay of most cardiac rehab programs.
If the results are positive, the next step will be a large multi-center trial comparing the interventions, says Blumenthal. Encouraging results would provide added ammunition for psychologists to make a strong case for being fully integrated into cardiac rehab programs, he says.
More research is also needed on the effectiveness of other cardiac rehab interventions besides group stress-management classes, says Cameron. Psychologists often hold such classes as part of cardiac rehab programs because they’re well studied and have a good rationale behind them. But few studies have compared individual versus group interventions, the timing and intensity of interventions, or whether different populations benefit equally from the same intervention, she says.
Psychologists also hope to make more inroads in heart-disease prevention, an idea that’s picking up steam in the AACVPR.
“With our knowledge of lifestyle change and behavior change, we’re probably better equipped than any other profession to help people prevent these health problems,” says Eichenauer’s practice partner, Glenn Feltz, PsyD.
Tori DeAngelis is a writer in Syracuse, N.Y.
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