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Close familial ties may be a source of stress as well as support for recovering heart patients, according to ongoing research from the Duke University Medical Center's department of psychiatry and behavioral sciences.
The findings are part of an as yet unpublished study of 290 cardiac patients being conducted by Redford Williams, M.D., director of behavioral research at Duke, and colleagues. They were reported by collaborator Beverly Brummett, Ph.D., this March at the annual meeting of the Society of Behavioral Medicine in New Orleans. The work is being funded by the National Institutes of Health's Heart, Lung, and Blood Institute as part of the Moderators of Social Support (MOSS) study.
Although social isolation has a negative impact on prognosis for heart patients, conflict with close family can trigger stress and depression, thus worsening prognosis, the authors concluded. Lead author Williams spoke with Psychiatric News.
Prior published research has established that the constellation of psychosocial variables that impact heart disease, including depression, isolation, hostility, and stress, "better predict general mortality than death from a single cause," said Williams. They generally occur, not as single risk factors, but as a cluster in the same people, he noted.
Scientists already know that both depression and isolation worsen prognosis in heart patients. Hostility alone, however, does not, said Williams. "Since all three are correlated, we thought it worthwhile to look at the combination of hostility and social support while in the hospital as predictors of depression one month later."
Relevant to this is that about 15 percent to 20 percent of heart patients meet criteria for major depression at the time of their heart attack, and up to 30 percent meet criteria for minor depression or dysthymia, Williams explained. Both major depression and lower levels of depression predict a poorer prognosis, he noted.
"We suspect dysthymia predicts a poorer prognosis because these lesser levels of depression during hospitalization identify those people likely to become depressed later on," said Williams.
The Duke study is significant, adding to the growing knowledge of the interaction between psychosocial factors and cardiovascular illness, remarked Joel Dimsdale, M.D., president of the American Psychosomatic Society and president-elect of the Society of Behavioral Medicine.
"This work is important, provocative, and clinically relevant," he commented. "Epidemiologists have long noted the power of social support, but certainly, as clinicians, we can recognize that there are 'ties that bind' as well as 'ties that blind.' On the other hand, correcting such interactions is not so straightforward, as Williams points out."
One of the goals of the Duke team's research was to develop a way of predicting, in hospital, who would be likely to develop depression after discharge, said Williams. They assessed depression one month after discharge and found that depression in hospital was a strong predictor, but that independent of that, low levels of social support also predicted higher depression following discharge.
"Interestingly enough," said Williams, "hostility did not directly predict depression one month later, but did, through its [capacity] to reduce social support, contribute to a higher incidence of depression. What all this tells us is that if you want to do something at the time a person has a heart attack to keep him from being depressed a month later (which has negative impact on prognosis), high hostility and low social support are all contributing, but hostility is doing so only through its impact on social support."
This suggests that an intervention in hospital targeting all four-depression, isolation, hostility, and stress-should be most effective in preventing depression a month later, he said. By reducing interfamilial conflict, that is, hostility, it is possible to increase social support, decrease the likelihood of depression, and hence improve the heart patient's prognosis, he explained.
Cognitive behavioral therapy (CBT) to reduce feelings of hostility in the heart patient, that is, to teach the patient to manage his or her anger better, is one approach, said Williams.
"When this is done with patients, it has been shown to prolong survival in both heart disease and cancer," he noted. The CBT training teaches assertiveness, communications skills, and "cognitive reframing" to help patients manage potentially stressful situations, including hostility from close family members, he noted.
The patients are "being put back in the situation with a set of skills that will enable them to cope better" with difficult family dynamics, said Williams.
Why not get family members to learn better conflict resolution skills, rather than place that burden entirely on the cardiac patient?
"It's hard enough to get the patient to change, much less the whole family," said Williams. "There are always going to be problems, but what we are aiming at is to help the patient cope better than before. A little bit of improvement in some of these conflict situations can make a big difference."