Cover Story

The man clutching his heart and falling dead of a heart attack during a fight with his wife has been the stuff of cliché. Now psychologists are producing the science to prove the cliché true--and using that science to design interventions they hope will save lives.

"Although there's still some debate, there is increased recognition among the medical community about the importance of psychosocial factors in cardiovascular disease," says James A. Blumenthal, PhD, a professor of medical psychology at Duke University Medical Center in Durham, N.C. "There are clearly more papers on psychosocial topics being published in the more mainstream medical journals, not just in the psychology journals. We're not just preaching to the converted anymore."

Blumenthal points to the literature review he and colleagues published in the pre-eminent cardiology journal Circulation in 1999 (Vol. 99, No. 16). "That the American Heart Association would afford us so much space is a testament to how important they consider psychosocial variables as potentially being," he says.

Today Blumenthal and other psychologists are producing clear evidence that psychosocial factors like hostility, anger, stress, depression and social isolation contribute to cardiovascular disease. They're showing that these factors influence the disease's development both directly and indirectly, through pathophysiological mechanisms and through unhealthy habits such as smoking and bad diets.

And they're beginning to come up with interventions that may help patients live longer, healthier lives.

Linking psychosocial factors and heart disease

Speculations about the link between psychosocial factors and cardiovascular disease are almost as old as medicine itself. In 1628 William Harvey first described the circulatory system and noted that emotions affect the heart. In 1897, William Osler--often called the father of internal medicine--described the typical heart disease patient as "a keen and ambitious man, the indicator of whose engine is always at 'full speed ahead.'" In the 1950s, cardiologists Meyer Friedman, MD, and Ray Rosenman, MD, began their work connecting Type-A traits--free-floating hostility, impatience and insecurity--with cardiovascular disease.

Despite this long history, controversy lingers in the medical community. For instance, a study of 630 Army personnel published in the New England Journal of Medicine (Vol. 343, No. 18) last year found no link between their levels of anxiety, hostility, depression and stress and their chances of developing clogged arteries.

In recent years, anger in particular has attracted great interest from researchers. In a prospective study published in Circulation (Vol. 101, No. 17) last year, for instance, psychologist Janice E. Williams, PhD, explored whether angry dispositions would lead to heart disease among 12,986 white and African-American men and women aged 45 to 64 at baseline. Conducted while Williams was at the University of North Carolina in Chapel Hill, the study used a questionnaire to assess what researchers call "trait" anger--a propensity for frequent, intense, long-lasting rages. Questions included whether study participants considered themselves quick-tempered or whether they felt like hitting someone when they got angry.

During a median follow-up period of about four and a half years, Williams and her colleagues checked to see if participants had had heart attacks or other cardiovascular problems. The results were striking. Among people with normal blood pressure, those with high scores on the anger scale were three times more likely to have suffered heart attacks or sudden cardiac death than were those with low scores. The findings held true even after controlling for risk factors such as smoking, having diabetes or weighing too much.

"This and other studies have shown a positive association between anger and heart attacks or sudden cardiac death," says Williams, who now works in the Cardiovascular Health Branch at the U.S. Centers for Disease Control and Prevention. "The implication is that individuals who find themselves prone to anger might benefit from anger management training."

Other psychologists have also become fixtures in the cardiac field, sharing their expertise in psychosocial factors. One is Karen A. Matthews, PhD, a professor of psychiatry, psychology and epidemiology at the University of Pittsburgh. In a study published in the Journal of the American Medical Association (JAMA) last year (Vol. 283, No. 19), she and her colleagues examined the role that hostility-- defined as a personality trait marked by cynicism, mistrust, anger and aggression--plays in predisposing young people to cardiovascular disease.

To explore the connection, Matthews and her colleagues assessed the hostility levels of 374 white and African-American men and women aged 18 to 30. A decade later, the researchers used a technique called electron-beam computed tomography to check participants' coronary arteries for calcification--an early sign of the hardening of the arteries known as atherosclerosis.

The researchers discovered that people who scored above the median on the baseline assessment of hostility were twice as likely to have coronary calcification than were those scoring below the median. These results held true even after the researchers controlled for demographic, lifestyle and physiological variables.

"Our study lets us predict really early which individuals are going to be at higher risk down the road," says Matthews. "From a prevention standpoint, that's very helpful. By identifying people early, you can design early interventions to retard further development of coronary artery disease."

Psychologists are also studying the ways psychosocial factors can exacerbate problems in people who already have heart disease. In an article in JAMA last year (Vol. 283, No. 14), for instance, psychologist David S. Krantz, PhD, reviewed the evidence he and other researchers have amassed demonstrating that both chronic and acute mental stress can negatively affect patients with coronary artery disease.

Krantz's own work has focused on identifying factors that trigger myocardial ischemia, which occurs when the heart doesn't get the blood supply it needs. In laboratory experiments, for example, he has provoked ischemia via such mental stresses as math exercises and harassment. He has also studied stress's impact on ischemia in everyday life by asking patients to keep detailed diaries of their activities and emotions.

"What surprises me about our findings over the years is that mental stress is about as powerful as strenuous exercise as a trigger for ischemia," says Krantz, professor and chair of the department of medical and clinical psychology at the Uniformed Services University in Bethesda, Md. "This suggests that stress management may be an appropriate addition to rehabilitation programs for patients with coronary disease."

Psychosocial factors also influence patients' recovery from heart attacks and other cardiovascular problems, researchers have found. In a study of 896 heart attack sufferers, for instance, psychologist Nancy Frasure-Smith, PhD, found that patients who were depressed were three times more likely to die in the year following their heart attack than those who were not depressed, regardless of how severe their initial heart disease was. Frasure-Smith, an associate professor of psychiatry at the McGill University School of Medicine and a senior research associate at the Montreal Heart Institute, published her study in Psychosomatic Medicine in 1999 (Vol. 61, No. 26).

The study also identified striking gender differences: Women were twice as likely as men to develop depression after a heart attack, with half of women and a quarter of men experiencing at least mild to moderate depression. Yet women's death rates were nonetheless the same as men's.

Social support may influence which depressed patients die, Frasure-Smith found in a study published in Circulation (Vol. 101, No. 16) last year. Based on interviews with 887 heart attack patients, the study found that depression's impact on survival was mediated by patient's perceived social support. Depressed patients who felt they didn't get enough support from friends and family members had the highest death rates. In contrast, depressed patients who reported the most support had the same death rates as nondepressed patients.

Intervening for patients' health

Now that researchers have data suggesting causal relationships between psychosocial factors and cardiovascular disease, the next step is to test whether interventions designed to influence those factors can prevent heart disease or improve the prognosis of those who already have it.

Researchers have been working in this area for years and have developed compelling evidence that such interventions cannot only enhance patients' quality of life but also dramatically improve their physical health (see sidebar):

  • In the Recurrent Coronary Prevention Project, for example, Friedman and his colleagues randomly assigned 1,013 heart attack patients to receive routine medical care, group counseling about cardiac risk factors or group therapy designed to modify Type-A behavior, plus counseling about risk factors. After four and a half years, patients who received the group therapy intervention had a 44 percent reduction in second heart attacks compared with the other two groups.

  • In the Lifestyle Heart Trial, Dean Ornish, MD, and his colleagues assigned 28 patients to a rigorous lifestyle-modification program that included group therapy, meditation and yoga as well as exercise and a low-fat diet. At the one-year follow-up, 82 percent of these patients saw regression in their atherosclerotic lesions compared with only 42 percent of the 20 patients in a control group. Patients in the experimental group also reported reductions in the frequency, duration and severity of their angina; angina symptoms actually worsened in the control group.

  • In Project New Life, Swedish psychologist Gunilla Burell, PhD, randomly assigned 261 post-bypass patients to receive routine medical care or one year of behaviorally oriented group therapy plus half a dozen "booster" sessions in the project's second and third years. At the follow-up five to six years later, patients in the treatment group were significantly less likely to have undergone further cardiac procedures, spent time in the coronary care unit, had heart attacks or died.

Now a ground-breaking trial called Enhancing Recovery in Coronary Heart Disease is taking this research to a new level. Funded by the National Heart, Lung and Blood Institute, the ongoing eight-center trial will determine whether psychological intervention can reduce heart attack patients' chances of having another heart attack or dying.

Currently in the follow-up stage, the trial randomly assigned about 2,600 heart attack patients to receive treatment as usual or a cognitive-behavioral therapy intervention targeting social isolation and major and minor depression, whether it was related to the illness or other aspects of patients' lives. Patients began with individual therapy, then progressed to group therapy. Results should be available about a year and a half from now.

"This is a landmark study in the field of psychology," says Robert M. Carney, PhD, principal investigator of the St. Louis site and professor of medical psychology and psychiatry at the Washington University School of Medicine. "It's the first opportunity we've had to show that what psychologists do can be potentially very important to the medical outcomes of certain groups of patients. It's very exciting."

Patients aren't the only ones who need interventions, however. Psychologists are also conducting research aimed at physicians and nurses who work with cardiovascular patients. Wayne M. Sotile, PhD, for example, has devoted his career to alerting health-care professionals about the need to pay attention to cardiac patients' psychosocial needs.

With funding from the cardiac device company Medtronic, Sotile and psychologist Samuel F. Sears Jr. recently explored the psychosocial needs of patients with implantable cardioverter defibrillators (ICDs) and also surveyed the family members, doctors and nurses who care for them. Implanted in the chest, the devices provide a lifesaving shock when patients' heart rhythms start going haywire.

The result was a manual called Brief Psychosocial Interventions for ICD Patients & Their Families, three audiotapes and patient materials, all designed to help health-care providers meet these patients' psychosocial needs. Since ICD patients will never get better, for example, health-care providers need to replace their usual emphasis on recovery with a new focus on coping skills.

"By choice or by default, physicians, nurses and allied health professionals are the ones who need to take responsibility for systematically and effectively addressing patients' psychosocial needs," says Sotile, director of psychological services for the Wake Forest University Cardiac Rehabilitation Program in Winston­Salem, N.C. "There aren't enough psychologists who are trained in the ins and outs of life with cardiovascular illness. It's a huge area of unmet need."

Rebecca A. Clay is a writer in Washington, D.C.