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A preliminary study from Duke University Medical Center in Durham, N.C., suggests that learning how to manage stress can sharply reduce the incidence of subsequent heart problems in patients with diagnosed heart disease.
The study of 107 people who had coronary artery disease and suffered from exercise-induced and mental-stress-induced ischemia found a 74 percent reduction in the risk of future cardiac events when compared with patients provided with medical care only. There was a reduction in fatal and nonfatal heart attacks and cardiac revascularization procedures including angioplasty and bypass surgery.
The study by psychologist James Blumenthal, Ph.D., and colleagues was published in the October 27 issue of Archives of Internal Medicine.
The patients were assigned to a four-month stress management program, supervised aerobic exercise, or routine medical care. Although the exercise group did slightly better than the group that had medical care only, the improvement was not statistically significant. The study measured psychological distress at baseline and at the end of the four-month intervention.
In a follow-up five years after the initial study, researchers found that 21 percent of the patients had suffered at least one adverse cardiac event. This included three in the stress-management group, seven in the exercise group, and 12 in the routine care group.
Although the study highlights the significance of psychosocial interventions in cardiovascular disease, heart patients should not be treated like psychiatric patients, Blumenthal told Psychiatric News.
"Cardiac patients are not necessarily psychiatric patients, and it would be inappropriate to treat them that way," remarked Blumenthal. "A nonpsychiatric approach to working with cardiac patients is more acceptable to them than a traditional psychiatric approach and, as demonstrated by results, is very effective."
Michael G. Goldstein, M.D., served on an APA task force for DSM-IV charged with examining the relationship between psychological factors and cardiovascular disease. He is the medical director of the Center for Behavioral and Preventive Medicine at the Brown University–affiliated Miriam Hospital in Providence, R.I. and a consultant to the hospital’s cardiac rehabilitation program. That program employs stress management training similar to that used in the current study, said Goldstein.
"This [study] is an example of how we can view behavioral health more broadly than just the delivery of psychiatric services to patients with identified psychiatric disorders," he commented. "Psychiatrists have an important role to play in developing interventions that help mitigate the impact of psychological factors on medical outcomes."
Ideally, studies such as this one should encourage clinicians to integrate some of these interventions into routine care so they are delivered by "the primary care physician, the cardiologist, and even at the community level at the patient’s home" through a "care manager" of some kind, said Goldstein. This is an area where managed care may be helpful in identifying less costly interventions that can be done outside the formal medical setting.
The study found that stress management reduced mental stress-induced ischemia, and aerobic exercise reduced exercise-induced ischemia, but not vice versa, said Blumenthal. "The results suggest there may be different mechanisms operating and that the two techniques [exercise and stress management] might have their own unique contributions to reducing coronary risk," said Blumenthal.
The research was, in effect, an educational program, Blumenthal said. It taught subjects what ischemia is, how stress affects it, and how to recognize stress.
Blumenthal and colleagues plan to do a randomized trial with a sample of about 200 people and look more closely at physiological mechanisms.
Although cardiac patients may have high stress levels, those levels "don’t necessarily reach the level of an Axis I diagnosis," said Goldstein. He agreed with Blumenthal that psychiatrists should not "overidentify these patients" as psychiatric patients.
"One of the positive aspects of the study was the attention paid to psychological and physiological mediators of outcome," said Goldstein. "On the other hand, those were all measures at baselines, so we don’t have the advantage of knowing whether the intervention actually altered the way" in which the subjects experienced psychological distress over the course of the five-year follow-up, he noted. That a five-year follow-up showed a decrease in adverse cardiac events, however, suggests strongly that the stress management training did result in long-term changes in coping style, observed Goldstein.
One particularly germane finding was that there was a statistically significant improvement in hostility levels after four months, Goldstein said. Hostility, and "the way in which hostility is expressed, that is, hostility that is internalized, rather than expressed," has been shown in prior studies to be closely associated with cardiovascular disease, he noted.
A necessary limiting aspect of the study was that it had to select a group of subjects willing to undergo an intensive four-month intervention, said Goldstein. "The important point here is that even in our cardiac rehab program, we are only reaching about 25 percent" of patients who come to Miriam Hospital due to a myocardial infarction. Some of the barriers are insurance related, others are caused by lack of geographical proximity to such programs, he noted.