June 1st, 2013

Psychiatrist proposes psychocardiology subspecialty

Despite four decades of research examining the link between heart disease and mental health conditions, Angelos Halaris, M.D., Ph.D., believes more must be done to raise awareness and promote meaningful action.

Halaris, medical director of adult psychiatry and professor in the department of psychiatry and behavioral neurosciences at Loyola University Chicago Stritch School of Medicine, formally proposed creation of a new subspecialty called psychocardiology at the joint congress of the World Psychiatric Association and International Neuropsychiatric Association in Athens, Greece.

His proposal was offered in conjunction with study findings showing that an inflammatory biomarker, interleukin-6 was significantly higher in the blood of 48 patients diagnosed with major depression than it was in 20 healthy controls.

Research has shown that 30 to 50 percent of patients who suffer depression are at risk of developing cardio vascular disease and 40 to 60 percent of heart disease patients have clinical depression. Interleukin 6 has an effect on the formation of serotonin, which is an important transmitter of emotional stability.

Halaris acknowledges that the link between depression and heart disease has long been researched and recognized, but feels now is the time to take that information to the next level. “There have been numerous studies in North America and abroad for many years but they haven’t been translated into meaningful programs to address co morbidity,” he says. “I think intuitively it is the right time to bring this concept forward in a general manner.”

He says that while the idea is in its infancy, he would ultimately like to see psychocardiology evolve as a discipline with its own journal, conference and multidisciplinary teams of mental health and medical professionals collaborating productively in various settings.

“The biggest challenge will be to get hospital administrators to get excited about this concept and forge ahead and develop multidisciplinary programs. There’s a degree of inertia amongst all of us. We need to break down barriers of silo structures of departments. The tendency is to each do our own thing and only talk across the hall when there’s a dire emergency,” Halaris says.

Although bringing this concept to reality could take a decade or more, Halaris says the next step is creating teams comprised of psychiatrists, psychologists, social workers, cardiologists, nurses and others working jointly in academic and medical settings toward a common goal. “We need to do a better job at assessing, diagnosing and treating patients to help prevent cardiac problems with depression or depression that potentially leads to cardiac problems later in life. There has to be interaction beyond referrals after the condition is too far gone.”

Halaris will be presenting his concept to the Association of Psychosomatic Medicine later this year and emphasizes that psychologists should and must play a major role in the process. Psychologists can play a significant role in helping patients manage stress using interventions involving lifestyle, behavioral, cognitive and other changes, he notes, while psychiatrists handle the medical component. Continuing education to physicians in the safe and correct use of medications in cardiac patients with psychiatric co morbidity is another part of the plan.

While Halaris is excited about the possibilities of collaboration, others express skepticism.

Gregory Fricchione, M.D., director of the division of psychiatry and medicine and Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital says there are already psychiatrists, cardiologists and integrative medicine specialists who focus their careers on “points at the interface of heart disease and mood and anxiety disorders…I don’t see the need to establish a new cumbersome bureaucracy – new training schemas, education committees, expensive board exams – to establish this field of work and study.”

Fricchione notes that the Benson-Henry Institute focuses on health promotion and illness prevention including cardiac rehab and wellness through relaxation response training and resiliency enhancement including nutrition advice and exercise. He adds that cardiology and psychiatry meetings feature sections and journals routinely publish articles “at the interface of cardiology, psychiatry and psychology.”

Robert Allan, Ph.D., co-author/editor of “Heart and Mind: The Practice of Cardiac Psychology,” is a New York-based clinical psychologist with practice specialties in cardiac psychology, stress and anger management, a clinical assistant professor of psychology in medicine at Weill Cornell Medical College and a professional associate at New York Presbyterian Hospital.

He feels that focusing only on the link between depression and cardiovascular disease is “narrow, short-sighted and behind the curve,” because it excludes major risk factors like anger and social issues. Allan says that the field of cardiac psychology is arguably informed by the largest empirical database in behavioral medicine, therefore Halaris’ proposal appears to be “coming a little late to the table.” Still, he agrees that psychologists need additional training in this field and require more knowledge about cardiology in order to interact with physicians and “understand the lingo.” In addition, with a groundswell effort to cut down on hospital readmissions, there’s an opportunity for clinicians to make an impact by partnering with other personnel in hospital cardiac rehabilitation programs.

Ellen Dornelas, Ph.D., a health psychologist at Hartford Hospital and associate professor at the University of Connecticut Health Center, says that even with 40 years of research behind it, there’s still a lot to learn about the cardiology/psychology link.

The author of “Psychotherapy with Cardiac Patients: Behavioral Cardiology in Practice,” says that cancer care has been ahead of the curve with a specialty for psycho-oncology, a journal devoted to the topic, an annual meeting and a professional organization. “I would like to see the field continue to evolve with similar professional activities.”

Also the editor of “Stress Proof the Heart: Behavioral Interventions for Cardiac Patients,” Dornelas agrees that there is room for improved integration of psychological delivery of care into the delivery of cardiac medicine. “In this regard, he (Halaris) is doing a good thing. It’s nice to take the next step forward,” she says.

By Susan Gonsalves

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