US specialists call for heart patients to be screened for psychological distress

Heart patients should be screened for psychological distress and, if necessary, referred for help from mental health professionals, according to the authors of research published today (Thursday 9 June) in the European Heart Journal.

The recommendation is the result of findings from one of the world's largest population-based studies on psychological distress in heart disease patients. It has established that men and women with heart disease in the USA suffer from higher than normal levels of distress – yet only a third have been seen by mental health professionals.

The research published in EHJ – an official journal of the European Society of Cardiology – is by Dr Amy Ferketich, Assistant Professor in the Division of Epidemiology and Biostatistics at the Ohio State University School of Public Health in Columbus, USA and Dr Philip Binkley, Professor of Medicine at The Ohio State University Department of Internal Medicine and Division of Cardiovascular Medicine.

The researchers took data from the 2002 National Health Interview Survey (NHIS) as their starting point. This survey – conducted annually by the National Center for Health Statistics and the Centers for Disease Control and Prevention – is the primary source of information on health and illness in the USA and is representative of all US households.

They analysed data on 17,541 men and women over 40 in the survey who had self-reported different forms of heart disease, including coronary heart disease (CHD), myocardial infarction (MI) and congestive heart failure (CHF). A questionnaire called K62 assessed the presence and level of psychological distress to establish whether a higher proportion of the study group experienced distress compared with the estimated prevalence among the healthy population, and if so, whether having more than one cardiovascular condition added to the levels of distress. Of the total, 644 patients scored high enough to be classified as suffering from psychological distress.

Dr Ferketich said: "The level of psychological distress among the healthy population is estimated to be 2.8%. But, we found that in our study over 4.1% with coronary heart disease and 6.4% with MI had psychological distress. And for those with congestive heart failure the figure was as high as one in 10."

She said that the increased level among those with CHD was not statistically significant, but for those who had MI it was double that of the healthy population and triple for those with heart failure. In each disease category the level of distress was higher if the illness had been diagnosed within the last 12 months.

"Because of the way the NHIS conducts its survey we know that our study group is representative of the general population in the USA with heart disease," she said. "This means there are over one million in the USA with a history of CHD, MI or CHF experiencing psychological distress."

There was a higher proportion of females, individuals with less than a high school education, Hispanics and non-Hispanic black people, the obese, non-drinkers, current smokers, the sedentary and individuals with hypertension or diabetes among heart disease patients with elevated distress levels.

"It's hard to know why, but we typically see this in research," said Dr Ferketich. "It may be that there are additional sources of stress in individuals in these groups."

The findings suggested that psychological distress was a significant co-morbidity (associated condition) of cardiovascular disease, according to co-author Dr Binkley.

"All the symptoms of psychological distress measured on the K6 – sadness, nervousness, restlessness, hopelessness, worthlessness and the feeling that everything is an effort – are more prevalent among respondents with one or more of the heart diseases. So, we are not talking here about an unequal distribution of one or two particular symptoms.

"What is perhaps most alarming, is the low prevalence of visits to a mental health professional. All heart disease patients with a diagnosis of serious mental illness should receive such services and these data indicate that only 31% to 35% have seen a mental health professional, although it is possible some may have been treated for distress by another type of practitioner."

The authors said there were some limitations to the study, but its main strength was that it involved a large population-based sample and a method of evaluating distress developed by experts in the field of psychological measurement.

"Our findings imply that psychological distress must be taken into consideration in the management of cardiovascular disease. Other studies have demonstrated a link between psychological distress and morbidity and mortality. All these findings provide the impetus for future investigations that assess the role that a medical and mental health care professional may have in altering these outcomes if they target distress."

Dr Binkley concluded: "Further investigation may indicate that screening is warranted, and certainly clinicians should be alert to this problem."