Bringing behavioral health into cardiac care

Clinical psychologist Kim Smolderenopens in new window, PhD, is codirector of the Vascular Medicine Outcomes Program and cofounder of the integrated heart and vascular psychology program at Yale New Haven Health in Connecticut, where she and her cardiology and psychiatry colleagues focus on helping patients navigate their cardiovascular disease risk. 

Providing psychotherapy to patients referred by cardiologists is a large part of Smolderen’s work, as is conducting cardiovascular outcomes research on the links between mental health and heart disease and how psychological distress shapes recovery and long-term outcomes. That research directly informs her clinical work and vice versa. 

Smolderen breaks down how depression, anxiety, and trauma factor into cardiovascular disease risk—and what clinicians need to know to support patients through it.

When people experience high levels of distress, their fight-or-flight system activates, which is the same system that activates the cardiovascular system. Under stress, your heart rate and blood pressure go up, and you breathe faster. If that happens chronically, it can contribute to cardiovascular risk such as higher blood pressure, inflammation, and artery problems, all of which increase the risk of heart disease and adverse cardiac events like heart attack and stroke. In one 2023 study, depression and anxiety increased the risk for a major cardiovascular eventopens in new window such as a heart attack or stroke by around 35%.

A person’s mental health can also impact the cardiovascular system indirectly. If people experience a high burden of stress, anxiety, or depression, and when there is an imbalance with the resources they have to deal with that distress, they may not be able to make lifestyle choices that support heart health. For example, sleep, exercise, and diet often suffer in times of high distress. People with untreated mental health symptoms may also have a higher likelihood to engage in behaviors like smoking or drinking alcohol, which we know negatively impacts heart health.

Cardiologists in our clinic refer patients who already have heart disease or are at risk for developing it. My work supports cardiovascular health by teaching people strategies to manage stress and provide psychotherapy for mental health conditions in the context of the person’s heart health and related behaviors. I apply insights from health psychology to help patients make the lifestyle changes that promote heart health, along with helping them manage mental health symptoms that can increase the risk of chronic distress and in turn, the risk of cardiovascular issues.

I primarily use cognitive behavioral therapy (CBT) and mindfulness-based stress reduction interventions to help patients referred for anxiety or mood disorders. For patients with a history of trauma, which can cause stress that affects heart health, I offer EMDR and trauma-focused CBT. Sometimes, I use medical hypnosis, which may be beneficial in individuals who also suffer from chronic pain, for example. Research suggests that when these symptoms are managed, patients’ quality of life improves, and they feel more equipped to take charge of their life and make desired changes that promote further heart health.

Experiencing cardiovascular events like strokes and heart attacks can cause a lot of anxiety. Even talking about emotional topics can provoke stress, because patients are afraid their heart rate might go up and cause more problems. While the physician can prescribe medication and lifestyle changes to improve long-term health, the cardiovascular psychology program can help people manage their emotions about their condition and teach people tools to self-regulate distress in their daily lives and provide support to find purpose and make changes in their lives that promote their cardiovascular health.

An example of patients referred to the clinic is those who have a condition called Takotsubo cardiomyopathy, a condition that we are still trying to better understand. It is thought that severe emotional distress, along with other factors, can cause one of the heart ventricles to weaken. Also called Broken Heart Syndrome, the condition is usually temporary, but it can cause serious cardiac events. After they’re treated and stabilized by their cardiologist, patients may get a referral to work on the underlying causes of their heightened distress, which could be unprocessed and prolonged grief of preexisting psychological trauma. We work together on reducing their mental load that they are carrying by reprocessing trauma and/or grief, which allows them to make healthy lifestyle choices to improve their long-term health and move past this impactful experience.

A common thread among patients is that they want to regain their sense of purpose in life. They recognize the importance of managing their condition, but they don’t want their life to be about their cardiovascular diagnosis. Clinical psychologists play an important role in supporting health behaviors while encouraging patients to align their day-to-day lives with the things they value, so they can find purpose outside of their condition. 

Clinical psychologists can also help patients manage distress and anxiety associated with heart conditions. It can help for clinicians to understand how impactful heart disease can be on a person’s life. There can be a lot of medications and doctor’s visits, which is a lot to take in. Supporting people as they navigate the medical system and their emotions, along with adopting a trauma-informed approach, is key overall for any individual with a medical diagnosis. Being aware that a lot of interactions with the medical system may act as a trigger that can reactivate existing trauma or can induce new medical trauma in patients, are key components of trauma-informed care design. 

If your patient is also seeing a cardiologist, encourage them to ask about integrated care opportunities in the cardiology practice. Clinical psychologists continue to play an important role in specialty medical settings, supporting improved physical and mental health outcomes for patients.