Mental Health as a part of Cardiac Rehabilitation
Psychological Counselling has become a part of Cardiac Rehabilitation. In any big hospital or rehab centre, a psychologist visits Cardiac patients to see if they need therapy. Ms V Smita, Psychologist, attached to the rehabilitation wing of the Institute of Cardio Vascular Diseases - Chennai, speaks from her experience on Stress, Personality factors and the risk of Coronary Heart Disease.
Which patients are likely to be in need of therapy?
I visit patients who have had a Myocardial Infarction (MI/Heart Attack) and those who have undergone surgery.
I also see patients who have been referred to me by doctors from their out patient clinics who are undergoing preventive rehabilitation. Patients with non cardiac chest pains may also need counselling.
Just talking to these patients enables me to understand if they need counselling.Of all patients who have had MI or a surgery, I find that a third need counselling.
What necessitates counselling in these patients?
There are different reasons.
Trauma: Many MI patients have led an active life and have suffered an attack suddenly. The intense pain, the life or death emergency they have undergone and the hospital stay have been traumatising experiences. They may take a long time to come out of the shock. A negative psychological sequence sets in. Loss of confidence, anxiety and depression may happen. Even when their physical health has been restored in such a way that they can resume their normal lifestyle, they are mentally still with the disease.
Geriatric: For older people, the problem might be a little different. They may be on the verge of retirement, or already retired. Their worries are about the imminence of death, the threat of physical dependence or the loss of a productive lifestyle.
Paediatric: Children who undergo surgery for congenital defects are affected by the painful surgery and hospital stay. They are treated with utmost care even after discharge from hospital so that they do not become agitated or exert themselves in any way. Later, when their incisions are fully healed, they expect the same kind of pampering and it becomes difficult for parents/ teachers to control them.
Family: Spouses get panicky about the patients’ health and fear that they are on the brink of death. Even when the patient recovers, they are under shock.
A long stay in hospital, painful treatment, restrictions also have a negative impact on patients. We address this also.
You mentioned preventive counselling. Could you explain the need for preventive counselling?
Stress is viewed as a risk factor for Coronary Artery Disease. When a treating cardiologist feels that a patient is stressed out and is unable to handle it himself, he refers the patients to the psychologist. Stress or risk can result from:
- Personality factors
- Environmental factors which can be temporary or permanent
- Unhealthy habits: Smoking, imbalanced diet, alcohol, and sedentary lifestyle
Personality Factors:
Current medical understanding holds that a Type A personality is at a higher risk of Coronary Heart Disease than Type B.
Some characteristics of a Type A Personality are:
Always in a hurry. Eats fast, walks and talks fast (often interrupting others)
- Restless when waiting
- Highly competitive
- Very precise
Ambitious, sets his own goals, takes work very seriously.
- Tries to do more than one thing at a time.
- Aggressive
Other Psychological Factors:
The Hostility Factor has to be assessed on an Anger Scale. Violence, irritability, intolerance etc are measured using questionnaires.
The overall mental status is also assessed.
Breaking Habits, which pose risk to the heart, is also difficult and may need a structured therapy programme.
What is achieved by counselling?
We help the patient identify the problem and look at solutions.
Are all patients who need counselling open to it?
No. Many people go into denial. Even when the doctor refers them to a psychologist, they will tell themselves that there is no problem, or that they can handle it by themselves.
There is a theory that stress is actually helpful?
Stress is an unavoidable fact of life. Everyone has ups and downs. Life would be dull without them! Some stress is actually helpful as it keeps you on your toes. But too much stress on your mind and body can make your miserable, worried, sad and ill.
One of the main causes of stress is change. Especially sudden or disagreeable change.
Too many or too drastic changes often result in harmful tension. Excess tension can result in anxiety and depression.
There can be chronic stress. Typical examples are living with a handicapped child, an alcoholic dependant or other family problems. Sometimes financial troubles can be the root cause of the problems. Daily stress can be suffered due to living conditions, facing an unsympathetic boss everyday etc.
Some stresses are temporary such as financial difficulties or a court case.
How is stress identified?
It is pressure from outside that can make you feel tense inside. It is sometimes serious enough to interfere with your normal daily activities
How should a patient deal with stress?
Prompt, correct treatment can help most troubled persons return to a normal life.Stress and tension cannot be eliminated, but we can learn to cope with them better. Our advice to patients is:
Understand the causes of stress, the depression and anxiety to which they can lead.
Your stress could come from any area in your life:
The first step in solving a problem is recognizing that it exists.
Help yourself and others. Talk it over. Take it easy. Try to keep things in perspective.
Keep stress in bounds before it causes trouble.
How can one strengthen body defences against stress?
Eat a healthy whole meal diet, which supplies all the nutrients your body needs to combat stress and make you feel more alert and energetic.
Eg:B12 protects against insomnia, fatigue & tension.
What combination of nutrients can strengthen the body defences against stress?
Nutritional Defence for the Adrenals
Pantothenic acid helps to increase the production of adrenal hormones, which are constantly being called upon during times of stress. Along with this B-complex vitamins may need to be taken.
Vitamin C also aids in adrenal hormone production and is needed to fight infection which could result when ill or stressed.
- Potassium requirements are higher during stress.
Nutritional defence for the pancreas
Zinc is a part of the insulin molecule and is easily lost under stress in response to the rise in blood sugar. It is also a constituent of approximately 25 enzymes involved with metabolism and digestion.
Nutritional Defence for the Thymus
Vitamin A is necessary to prevent the thymus gland from shrinking during times of stress. Evidence also shows that vitamin A reduces the risk of stress related stomach ulcers. The body's fighting mechanism and will do its best to aid you in times of stress. Learning how to assist your body in this fight could be of extreme value to your health. Prevention is the most important key in your defence against stress. A careful balancing of body chemistry, through the use of vitamin and mineral supplements, relaxation techniques, exercise and intelligent diet puts the body in a position to experience life's situations with a minimal negative response to stress.
However, only a doctor can prescribe supplements after evaluating your health. Fruits and fresh vegetables can increase your daily intake of nutrients.
Are there other states of mind that affect quick recovery?
Anxiety and Depression are also not helpful.
Anxiety
This is a worried, "uptight" feeling. It is a vague fear that something bad or unpleasant is going to happen, even if there is no real threat.
When your body is subjected to stress, it undergoes physiological changes. Adrenaline floods your blood stream, your blood pressure rises, your muscles flex, your heart races, you start to sweat and feel very tense. Even when these symptoms subside, you may be left feeling fatigued, giddy and anxious.
Anxiety may result from holding back feelings we cannot cope with or understand; or it may grow out of a conflict between what we would like to do and what we thing we ought to do.
Everyone has a certain amount of anxiety. To a degree it is a natural, helpful response to stressful or threatening situations.
But prolonged anxiety can lead to serious problems, such as ulcers, high blood pressure, inability to enjoy life and the world.
How does one identify anxiety?
The common symptoms of anxiety are:
- Nervousness
- Trembling
- Dizziness
- Pounding heart
- Inability to slow down or relax
- Abnormal eating habits
- Troubled breathing
How do you help a patient deal with anxiety?
By encouraging a patient to believe that he is in control of his life and body.That he alone can decide on the quality of his life, and to what degree of stress he wishes to subject himself.
Help him believe that he can handle it; that it can be a feature of his life as long as he does not allow it to take control of him.
Depression
It is a feeling of sadness or disappointment that leads to apathy and withdrawal for no specific reason.
Depression may result from frustration, the inability to live up to expectation, or from a disappointment or compromise.
Depression is a formidable problem in cardiac convalescence and rehabilitation. The “home coming depression”, very common in patients after a cardiac event, is often the result of a feeling of weakness and fatigue upon returning home.
This weakness, interpreted by the patient as a loss of capacity, may initiate depression or further compound an already existing state of depression.
Some depression is normal - a reaction to the reality when it falls short of what's hoped for.
But prolonged depression is a serious problem. Long lasting feelings of worthlessness and isolation can lead to suicide.
How is depression identified?
The most commons signs of depression are:
- Fatigue, sleeplessness
- Inability to concentrate
- Restlessness, boredom
- Lack of interest in food, sex, life in general
- Feelings or worthlessness, hopelessness
What can a patient do to be in better mental health?
A lot can be done to keep tension within reasonable limits.
- Talk it over: Discuss the problems with a close friend or with the people involved.
- Plan work: Tension & anxiety really build up when work seems endless. Plan work to use time & energy more efficiently.
- Be realistic: People who expect too much of themselves can get tense if things do not work out. Set practical goals and expect to be successful.
- Take a break: A change of pace, no matter how short, gives you a new outlook on old problems.
- Avoid stress: Whenever possible, plan to avoid too many big changes at the same time.
- Learn to relax: Everyone can teach himself to relax. Just a few minutes of peace & quiet every day make a big difference. Try it. Special relaxation techniques can induce a relaxed mental & physical state.
- Exercise regularly: Swim, walk, bicycle-Any favourite sport will help let off steam and work out stress.
- See the physician: A check up is always important especially if one is busy.
A positive outlook is always helpful.
Source: The above material was prepared with the help of the Cardiac Rehabilitation unit at the Institute of Cardio Vascular Diseases, Chennai.
