CHAPTER 111: BEHAVIORAL CARDIOLOGY: EPIDEMIOLOGY, PATHOPHYSIOLOGY, AND CLINICAL MANAGEMENT

Behavioral cardiology is a dynamic new field that studies the role of psychological, social, and behavioral factors that contribute to health and cardiac disease. The field includes various components, as summarized in Table 111–1. These include the epidemiologic study of psychosocial factors that serve as risk factors for cardiovascular disease (CVD) and the pathophysiologic basis for this risk. In addition, the field has become increasingly focused on examining positive psychosocial factors that promote health and longevity and the physiologic basis for such buffering. In the clinical realm, the field seeks to examine psychological approaches for modifying adverse health behaviors that promote disease, such as poor diet and physical inactivity, and for developing approaches that help manage psychosocial risk factors, such as chronic stress, which can contribute to adverse health behaviors and promote disease. Due to the large breadth of this growing field, each of these areas will be reviewed in a general rather than in-depth manner, with references limited to examples of representative studies.

By the late 1990s, considerable evidence had accumulated to identify the role that acute stress can exert in precipitating myocardial ischemia as well as to establish the role of chronic psychosocial factors that are associated with an increased risk for CVD, including depression, hostility, work stress, and social isolation.¹ The epidemiologic evidence supporting the clinical importance of behavioral and psychosocial risk factors has since grown and now includes a number of meta-analyses concerning individual psychosocial risk factors. A comprehensive list of behavioral and psychosocial factors that have now been studied for their relationship to clinical heart disease is listed in Table 111–2.

Health Behaviors

Various negative health behaviors are strongly associated with an increased risk for CVD, including poor nutrition and or weight control, physical inactivity, and smoking. Each of these behaviors is covered in other chapters of this book (see Chaps. 27, 30, 31, and 106).

Sleep

Poor sleep is a newer arena that has been increasingly studied for its adverse health effects. The study of sleep has included both the examination of sleep duration and the quality of sleep. The definition of short and long sleep is arbitrary, but in most studies, short sleep has been defined as ≤ 5 to 6 hours a night and long sleep as > 8 to 9 hours a night. Repeatedly, studies have found that both short and long sleep, fragmented sleep, and insomnia have been linked to an increased risk for CVD. A meta-analysis of 15 studies found short sleep to be associated with a greater risk of either developing or dying from CVD (relative risk [RR], 1.48; 95% confidence interval [CI], 1.22-1.80), and a similar risk was associated with long sleep.² Similarly, a meta-analysis of 13 prospective studies involving 122,501 subjects found that insomnia was associated with a risk ratio of 1.45 (95% CI, 1.29-1.63) for the development of CVD or cardiac events.³

These epidemiologic studies have been complemented by a wide variety of studies that have documented consistent pathophysiologic abnormalities in combination with poor sleep, both on an observational basis and in experimental studies that have acutely reduced sleep by various lengths of time among healthy volunteers. These abnormalities include alterations in neuroendocrine and autonomic function, elevation in levels of inflammatory proteins, and an increase in appetite and weight gain, which may be mediated in part through the reduction in the secretion of leptin, an appetite-suppressing hormone, and an increase in ghrelin, an appetite-stimulating hormone, as people get less sleep.^4,5,6 Meta-analytic studies have also demonstrated an association between short sleep duration and two important mediators of CVD: hypertension⁷ and type 2 diabetes.⁸

The future study of sleep duration, however, may benefit from more investigation that relates outcomes according to the reasons for short sleep. For instance, it is yet to be distinguished how short-sleepers who restrict sleep in the pursuit of highly purposeful activity differ in health effects from those who are short-sleepers due to worry or other psychological factors.

Depression

Depression, which ranges from mild symptoms to major depressive disorder, is particularly common in cardiac populations. Major depression, which is characterized by depressed mood and/or lack of interest in nearly all activities for ≥ 2 weeks, in conjunction with at least four to five out of nine other psychological symptoms (eg, change in appetite, insomnia, fatigue, guilt), is found in approximately 15% of cardiac patients, and milder depressive symptoms also occur in another 15% of cardiac patients.⁹ Epidemiologic studies have consistently demonstrated the potency of depression as a risk factor for cardiac events among community cohorts without preexisting CVD; it is also a risk factor for recurrent events among patients with preexisting CVD. In a large meta-analysis of 54 studies, the adjusted risk ratio for cardiac events was increased nearly two-fold among depressed versus nondepressed subjects in both community cohorts and patients with prior CVD.¹⁰ Epidemiologic studies have also demonstrated a gradient relationship between the magnitude of depressive symptoms and the occurrence of adverse cardiac events. Notably, even mild levels of depression or of overall psychological distress have been found to be associated with an increased risk of adverse events compared to patients without symptoms, as demonstrated, for instance, in a recent large follow-up of 68,222 individuals who were assessed for psychological distress using the 12-item General Health Questionnaire (Fig. 111–1).¹¹

Anxiety Syndromes

Anxiety is another negative emotion that is common in medical practice. Anxiety symptoms may range from mild symptoms to severe psychiatric conditions, including phobias, panic disorder, generalized anxiety disorder, and post-traumatic stress disorder (PTSD). The presence of anxiety symptoms was found to be associated with an increased incidence of CVD in a meta-analysis of 20 studies (hazard ratio, 1.48; 95% CI, 1.15-1.38), but the analysis was notable for considerable variability in results among individual studies, with only 50% of the studies manifesting a significant adjusted association between anxiety and CVD.¹² Another meta-analysis of 12 studies involving 5750 post–myocardial infarction (MI) patients found a 36% increased risk in overall mortality for those with anxiety symptoms.¹³

Anxiety syndromes requiring psychiatric help are consistently associated with substantial cardiac risk. For instance, in a 10-year follow-up of 438 acute post-MI patients, Roest et al¹⁴ noted an approximately two-fold adjusted risk for adverse outcomes among patients with generalized anxiety disorder, and comparable risk was reported in the Heart and Soul Study.¹⁵ A meta-analysis of 12 studies reported an adjusted hazard ratio of 1.49 (95% CI, 1.24-1.74) for CVD among individuals with panic disorders,¹⁶ and a meta-analysis of six community cohort studies found a hazard ratio of 1.55 (95% CI, 1.34-1.79) for CVD among those with PTSD.¹⁷ The risk associated with PTSD is further highlighted by a study of 562 twins who were followed for a mean of 13 years.¹⁸ The presence of PTSD was associated with a 2.2-fold increase in CVD and greater abnormalities on myocardial perfusion imaging for twins who had PTSD compared to their counterpart twins without a history of PTSD.

Hostility and Anger

Hostility is a negative cognitive state that has been widely studied with respect to its potential link to CVD. Hostility is a broad construct that encompasses the traits of anger, cynicism, and mistrust. Interest in this construct was an outgrowth of original work regarding “type A behavior pattern,” a triad of hostility, impatience/time urgency, and a highly competitive drive that is no longer studied as a result of inconsistent findings regarding this proposed behavioral construct. A variety of studies have linked hostility/anger to various pathophysiologic determinants of CVD and to progression of atherosclerosis,⁹ but epidemiologic study in this arena has been inconsistent. A meta-analysis of 25 studies found a modestly increased risk for cardiac events in association with anger/hostility among healthy population (RR, 1.19; 95% CI, 1.05-1.03), and a similar increase in a meta-analysis of 19 studies involving patients with known CVD was noted (RR, 1.24; 95% CI, 1.08-1.42).¹⁹ Both a tendency toward some degree of self-denial or lack of self-awareness among patients with hostility and anger and potential limitations in the questionnaires that have been used to assess this psychosocial construct represent challenges in studying this domain.²⁰

Pessimism

The role of optimism versus pessimism has attracted increasing attention as a risk factor for cardiac events. Pessimism is commonly characterized as a general personality disposition toward expecting negative outcomes in the future; optimists tend toward expecting positive outcomes. Prior study has also assessed optimism versus pessimism according to one’s “explanatory style.” Pessimists have an explanatory style of invoking self-blame for negative events, as well as a tendency to view negative events as persistent and affecting many aspects of their lives. Optimists, in contrast, tend to avoid self-blame, and view negative events as transitioning and limited in scope. Both dispositional and explanatory pessimism have been linked to negative health outcomes. An increasing number of studies have established a consistent relationship between pessimism and reduced longevity and increased risk of cardiovascular events and stroke.²¹ As with most psychosocial risk factors, a dose-response relationship has been noted between the level of pessimism/optimism and the occurrence of cardiac events.

Chronic Stress

Chronic stress can be studied objectively through exposure of experimental animals to stress under controlled circumstances. A particularly useful model in this regard has been the study of chronic stress in cynomolgus monkeys (Macaca fascicularis), since these animals both exhibit social behaviors that can be well quantified and develop atherosclerosis in a manner that is similar to humans. When male monkeys are placed into social groups, they fight among each other until they establish a pecking order from the most dominant to submissive monkeys.²² Fighting then subsides. However, by periodically rearranging the distribution of monkeys within groups, a condition of chronic fighting is established. Among male monkeys who were subjected to the experimental condition of changing groups, dominant male monkeys (who tend to do the most fighting) developed considerably greater atherosclerosis compared to dominant monkeys in stable social groups or to submissive monkeys (Fig. 111–2).

Among individuals, chronic stress has most commonly been studied in relationship to work stress. One of the earliest models of work stress that continues to be studied is that of “job strain.” The model posits that job strain is present when individuals demonstrate a high sense of job demand with little job latitude. Studies have consistently shown an increased risk for CVD among those individuals reporting job strain, but the relationship has been relatively modest. For instance, a recent meta-analysis found only a 1.23-fold increase in the incident risk of CVD in association with measurement of job strain.²³ Various other factors may be important to consider when assessing work stress, including the chronicity of the stress. In the INTERHEART study (Effect of Potentially Modifiable Risk Factors Associated With Myocardial Infarction in 52 Countries), the odds ratio for developing MI was 1.38 (95% CI, 1.19-1.61) for those experiencing intermittent work stress, but 2.14 (95% CI, 1.73-2.64) for those experiencing chronic work stress.²⁴

Another common stressor is marital stress. Research in this regard has focused on both marital status and strain within marriages. A large meta-analysis of 104 studies that examined data concerning the risk of death associated with marital dissolution found that the risk of death among those who divorced or separated, compared to married individuals, was age dependent, with risk being highest among younger men who experienced divorce or separation (Fig. 111–3).²⁵ Study into the cardiovascular health effects of psychological stress within marriages, however, has been quite limited. A few epidemiologic studies, primarily in women, have found that measures of marital stress were associated with an increased frequency of cardiac events, but more consistent study is needed to better evaluate this common stressor.

A third stressor is the enduring effects of childhood abuse or trauma. A meta-analysis of 24 studies has linked childhood abuse to an increased risk of CVD and other adverse medical outcomes in adulthood.²⁶ In a particularly large study, the Nurses’ Health Study 2,²⁷ which involved a 16-year follow-up of 66,798 women, a history of childhood abuse was common, having occurred in approximately one-fifth of the women, and within this subgroup, it was associated with an approximately 1.5-fold increase in the onset of cardiovascular events by middle age. Adult risk factors such as smoking, diabetes, and body mass index, as well as psychosocial factors, such as depression, accounted for the majority of this risk. Childhood abuse can also induce persistent neuroendocrine and immune dysfunction in adulthood.^28,29

Acute and chronic illness can also produce stress. For instance, Edmondson et al³⁰ recently reported a 12% prevalence of PTSD among acute coronary syndrome (ACS) patients in a meta-analysis of 24 studies; in three of these studies, subsequent outcome data indicated a doubling of subsequent risk of death among ACS patients who had PTSD.

Future study regarding situational stressors may further evaluate how individual differences in perceived stress may affect clinical outcomes. Individuals vary widely in their perceived sense of stress in response to a given life situation, depending on personality, resilient resources, and other factors. One of the interesting aspects regarding stress, in this regard, is an apparent U-shaped relationship between the degree of life adversity and an individual’s sense of satisfaction (Fig. 111–4).³¹ A likely reason for this U-shaped relationship may be a basic human need to seek growth and meaning, as described by Ryff.³² That is, people are driven to seek goal-oriented activities and challenges, which provide a source of purpose, life satisfaction, and self-esteem. In the absence of challenge, humans may develop boredom and dissatisfaction, which may lead to negative downstream health effects.

In addition, the meaning that is invested within a given life situation may be a potential modifier of perceived stress and clinical outcomes. For instance, caregiving is a stress that has not been uniformly found to be associated with an increased frequency of clinical events. Potentially, the amount of meaning associated with the caregiving experience could be an important modifying factor,³³ but this postulate requires prospective study.

A further aspect regarding perceived stress is the self-beliefs or concerns that patients may have regarding the potential toxicity of stress. This issue was recently studied by Keller et al.³⁴ They assessed mortality in a representative US sample of 28,753 individuals, who rated both their level of perceived stress and their perception as to whether their stress was impacting their health. Among those who reported a high level of stress, increased mortality occurred only among those who also self-appraised their stress as harmful to their health. Pending more prospective study, this finding suggests that modifying patients’ self-beliefs regarding the toxicity of stress might be a potentially useful behavioral intervention.

Social Isolation and Poor Social Support

As with chronic stress, the pathophysiologic effects of social isolation can be studied experimentally in social animal species. As summarized by Capiocci et al,³⁵ placing social animals into isolation has been shown to produce adverse physiologic effects. A direct effect of social isolation upon atherosclerosis has been assessed quantitatively in female cynomolgus monkeys. Compared with dominant female monkeys, female monkeys who are submissive are more prone to atherosclerosis when fed a high-cholesterol diet, but placing monkeys in a single cage results in substantially greater amounts of atherosclerosis compared to monkeys housed in social groups (Fig. 111–5).³⁶

The role of social factors upon human health has been repeatedly demonstrated. The classic Alameda County study was the first to link risk of death to the size of one’s social network in a large epidemiologic study.³⁷ This study demonstrated a strong inverse gradient relationship between the size of one’s social network and subsequent risk of death (Fig. 111–6). The study of social health has subsequently expanded to include many aspects of social life, including the size, structure, and frequency of contact within social networks, and various aspects of functional support, including informational and emotional support. Both structural and functional support are important mediators of health outcomes. A recent meta-analysis of 148 studies indicated a large effect size regarding the health buffering provided by strong social support.³⁸ An index of social integration was associated with an approximately two-fold increase in survival in this meta-analysis.

Low Socioeconomic Status

Socioeconomic status (SES) is generally characterized as a composite of factors, such as education, occupational status, economic resources, and social status. Longitudinal studies have consistently demonstrated a strong inverse gradient between various measures of SES and adverse cardiac events,³⁹ including recent novel data based on tax and Social Security records, which demonstrate a marked gradient between income and life expectancy in the United States.⁴⁰ Among children, low SES status also augurs for a greater risk of adult CVD risk factors and adverse cardiac outcomes.⁴¹ Low SES has the capacity to serve as a composite chronic stressor because of the various factors that make stressful experiences more likely in low SES environments, including a greater likelihood of more financial strain, less job security and latitude, poorer housing conditions, more impoverished neighborhoods, and/or a diminished sense of public safety. Several mechanisms appear to account for the increased risk associated with low SES. First, low SES is associated with a higher frequency of poor health habits, such as poor nutrition and overeating, smoking, and physical inactivity.⁴² Second, the stress associated with low SES (eg, economic hardship, job insecurity) increases the prevalence of depression and other mental status parameters that may in turn increase CVD.⁴³ In addition, pathophysiologic mechanisms that can promote CVD are also more prevalent in low SES populations, such as more autonomic and metabolic dysfunction.^44,45

Synergy Among Psychosocial Risk Factors

Although epidemiologic study tends to assess individual psychosocial risk factors in isolation, these factors have a high tendency to cluster in real life. Various lines of evidence indicate that clustering of psychosocial risk factors increases the risk of clinical events. For instance, poor social support can augment the health impact of life stress. In an early study in this regard, Ruberman et al⁴⁶ found that high levels of life stress or social isolation each doubled the risk of all-cause death compared to patients with low levels of each risk factor among 2230 post-MI patients followed for 3 years. However, when both risk factors were present, death risk was substantially increased compared to the presence of one risk factor alone (Fig. 111–7).

Similarly, psychological stressors are also potentiated when occurring among individuals with low SES.^47,48 Depression and anxiety are highly comorbid, and when both are present, the likelihood for future clinical event rates is elevated compared to the presence of either emotion alone.⁴⁹ The prognosis associated with psychosocial stress may also be potentiated by the presence of poor health habits, such as physical inactivity (Fig. 111–8).⁵⁰

Pathophysiology Of Negative Psychosocial Stressors

The pathophysiologic mechanisms by which psychosocial risk factors promote atherosclerosis and increase the risk for cardiac events has been extensively studied, both in human studies and in experimental animal studies. Psychosocial risk factors exert their deleterious effects by two basic pathways: a wide variety of direct pathophysiologic effects and negative impact on health behaviors (Fig. 111–9).^9,21 When psychosocial stress is chronic, such as in depression, it can result in persistent activation of the hypothalamic-pituitary-adrenal axis and dysregulation of the sympathetic nervous system, leading to a rise in serum cortisol levels and elevated norepinephrine levels. The result is widespread systemic effects, which vary in presentation according to the type and magnitude of stress. In depression, these effects include autonomic dysfunction; a variety of endocrine-related abnormalities, including central obesity, insulin resistance, and a three-fold increase in the risk for diabetes; increased risk for ovarian dysfunction and osteoporosis; endothelial dysfunction; a variety of platelet abnormalities; and unfavorable alterations in brain plasticity, including enlargement of the amygdala (the brain’s fear center) and reduction in the size of the hippocampus and prefrontal cortex.^1,9 Other pathophysiologic effects of chronic stressors may include increased risk of arrhythmias, hypertension, and enhanced cardiovascular reactivity (ie, the tendency to manifest increased heart rate and blood pressure responses to physiologic stimuli with prolonged time to recovery to baseline measurements). Cardiovascular reactivity has been linked to a higher frequency of subsequent hypertension and carotid intima-medial thickness according to a meta-analysis of 36 studies.⁵¹

There are two principal behavioral mechanisms by which psychosocial risk factors also exert their pathogenic effects. First, extensive study has repeatedly demonstrated that unhealthy behaviors, such as overeating, poor nutritional choices, physical inactivity, and smoking, are more common among patients with psychosocial risk factors such as depression, anxiety, pessimism, loneliness, and chronic stress. Second, these same psychosocial factors tend to impede the ability of patients to comply with behavioral changes recommended by their physicians. For instance, a meta-analysis of 122 studies found that various aspects of social support each had a significant negative effect upon patient adherence to medical regimens.⁵² Similarly, another meta-analysis found a three-fold increase in poor patient adherence among depressed versus nondepressed patients.⁵³

In recent years, there has been an increasing focus on the health benefits associated with positive psychological factors. It is now well recognized that each of the major psychosocial domains can be characterized according to a spectrum, ranging from positive factors that promote health to negative factors that promote disease (Fig. 111–10).²¹ Increasing evidence has delineated several mechanisms by which positive psychosocial functioning promotes health. This includes physiologic buffering, which may be, in part, a result of reduced activation of the neuroendocrine and immune systems (as opposed to the hyperarousal seen with negative stressors), as evidenced, for example, by optimism.^54,55,56 Second, positive psychosocial factors are associated with an increased likelihood of positive health behaviors.⁵⁷ Third, positive psychosocial factors may help enhance coping resources, including cognitive functions, social resources, and problem-solving capacities.^9,58

Epidemiologic data support the importance of positive psychosocial factors. For instance, Chida and Steptoe⁵⁹ performed a meta-analysis of studies that assessed the impact of positive psychological well-being upon mortality in both community cohorts and diseased populations. Psychological well-being had a favorable effect on survival in both groups. This initial meta-analysis included a broad definition of well-being, including such factors as positive mood, optimism, and life satisfaction. Recent study has begun to further focus on the relationship between specific positive psychological constructs and cardiovascular outcomes.

An important construct in this regard is that of life purpose, which has been proposed as a basic psychological need by many theorists. In a recent meta-analysis of 10 prospective studies involving over 136,000 subjects assessed for both all-cause mortality and cardiovascular events, the risk ratio for cardiac events was 0.65 prior to risk adjustment and 0.83 after risk adjustment.⁶⁰ Similar findings were noted for all-cause mortality. The results were highly consistent among the studies constituting this meta-analysis. A higher sense of purpose has also been linked to a reduced risk of stroke,⁶¹ future physical disability,⁶² and dementia.⁶³ Purpose in life may be health-promoting through a number of mechanisms. Preliminary data suggest that life purpose may provide positive physiological buffering,⁶⁰ although the data are scant in this regard. Purpose in life may also serve to promote healthier behaviors and less use of medical services. In addition, purpose in life may be associated with greater resilience, as suggested by a meta-analysis of 70 studies that found that purpose in life was associated with a greater sense of competence, stronger social integration, and more positive affect.⁶⁴

Another measure of positive health is the presence of vitality, defined as the subjective sense of feeling energetic, which is both pleasurable and activating (ie, creating a greater tendency to do things).⁶⁵ As previously proposed,⁹ the presence of vitality is a function of both physical and psychological well-being (Fig. 111–11). The presence of vitality can help support coping mechanisms for dealing with life stress and the regulation of emotions, which are important resilience mechanisms. Conversely, successful coping and emotional regulation are mechanisms that help preserve energy and promote vitality.

Kubzansky and Thurston⁶⁶ assessed the significance of a baseline measurement of vitality in a 15-year follow-up of 6265 individuals who were initially free of CVD. A dose-response curve was evident between baseline vitality and subsequent development of CVD. Those having the highest vitality at baseline had the least development of CVD. Similarly, emotional vitality has been associated with a decreased risk of stroke⁶⁷ and hypertension.⁶⁸ On the other end of the spectrum is the presence of “vital exhaustion,” a condition of excessive fatigue, feelings of demoralization, and increased irritability, which has been postulated to be often a result of prolonged distress.⁶⁹ Epidemiologic study has linked vital exhaustion or measurements of exhaustion to an increased risk of cardiac events and/or all-cause mortality. Vital exhaustion was recently compared to other CVD risk factors in a follow-up of 8882 individuals who were initially free from CVD in the Copenhagen City Heart Study.⁷⁰ Vital exhaustion was found to be a strong independent risk factor for the development of CVD in both sexes, with manifestation of a strong risk-adjusted gradient relationship. Vital exhaustion has been found to be associated with metabolic and coagulation abnormalities, inflammation, and low cortisol levels.

Behavioral cardiology targets both the management of behavioral risk factors for CVD, such as physical inactivity, poor diet, weight management, and sleep hygiene, and the management of the psychosocial risk factors that contribute to the pathogenesis of CVD, promote adverse health behaviors, and impede adherence to behavioral recommendations.

A foundational principle in clinical management is the strong reciprocal relationship that exists between the management of health behaviors and psychosocial risk factors. The management of health behaviors can promote psychological well-being through multiple mechanisms. For instance, a strong evidence base relates exercise to psychological well-being through at least four pathways, as summarized in Fig. 111–12.

First, exercise can favorably impact psychological mood, as evidenced through cross-sectional studies of community cohorts that have observed less depressive symptoms among those who exercise, as well as by longitudinal studies that have demonstrated a lower frequency of subsequent depression among subjects who were physically active at baseline.⁷¹ In addition, a meta-analysis of 25 randomized studies that compared exercise with either standard therapy for depression, placebo, or no treatment found a large treatment effect for reducing depression among those randomized to exercise.⁷² The strongest evidence comes from three randomized trials conducted by Blumenthal and colleagues. In each trial, exercise training was as effective as antidepressant medication in the reduction of depressive symptoms.^73,74,75 Second, exercise has been shown to improve executive function and cognitive vitality and appears to provide a protective effect against the development of dementia.^76,77 Third, newer data indicate that exercise serves to reduce the pathophysiologic effects associated with psychosocial risk factors. For instance, studies indicate that physical fitness is associated with reduced heart rate, blood pressure, and cortisol responses to psychosocial stress.⁷⁸ Physical fitness can also buffer the relationship between depression and inflammation,⁷⁹ reduce the likelihood of impaired glucose metabolism in response to chronic stress,⁸⁰ and reduce the effect of chronic stress on telomere length.⁸¹ Fourth, exercise can aid in the management of other health behaviors, including diet and sleep. Conversely, psychosocial interventions can be used to improve health behaviors, as will be discussed next.

The management of patients’ health behaviors is intrinsically challenging. Poor adherence to medication usage is common, and poor adherence to diet, exercise, and other behavioral suggestions is even more common. Physician management of patients’ health behaviors can be addressed according to a three-component model of behavioral change: (1) promoting patients’ motivation for initiating behavioral change; (2) assisting patients in their execution of behavioral health goals; and (3) helping patients to sustain the long-term practice of new health behaviors. Each of these phases of behavioral change has its particular challenges. Instilling motivation is essential, as patients are unlikely to either initiate or maintain new health practices for long without motivation. However, motivation itself is often not sufficient. In fact, extensive study has shown that motivation only accounts for approximately 30% of the variance in human behavior. More often, patients fail to maintain new health behaviors either because of poor execution of health goals or because of relapse into old behavioral patterns. Representative techniques that can be used to assist patients in the management of their health behaviors are listed in Table 111–3.

Enhancing Motivation

The receptive patient is often responsive to well-delineated information as to his or her risk for disease and the modifications in lifestyle that are thus needed. In addition, the enthusiasm with which physicians impart health information and behavioral advice can have an impact on the motivation of receptive patients. Often, however, additional motivational techniques are needed to encourage the unreceptive patient. These techniques can take the form of external or internal motivation. Examples of external forms of motivation include the use of incentives and warnings and providing instrumental support (eg, case manager, follow-up calls). Although these techniques can be useful in individual patients, fostering patient autonomy by increasing patients’ intrinsic motivation is particularly desirable, because long-term maintenance of behavioral change is more likely with intrinsic versus extrinsic motivation. A practical technique for fostering intrinsic motivation involves having patients pause after imparting health advice and then asking patients why they might want to take on a suggested health goal. Having patients contemplate their own “why” for initiating a health goal and then verbalizing it improves patients’ ownership over their own health goals. Similarly, patients should be encouraged to identify the methods (ie, the “how”) by which they would prefer to pursue their new health goals.

Another important motivational approach is establishing health goals according to the principle of “self-efficacy.” As first established by Bandura,⁸² this principle establishes that the more someone believes that a certain goal can be accomplished, the more that person is willing to try. This principle guides physicians to modulate patients’ health goals toward “small wins” that patients believe they can achieve. For example, guidelines recommend that individuals should aim for 30 minutes of moderate aerobic exercise four to five times per week as well as strength training at least two times per week. However, most sedentary patients will not initially be able to comply with such a goal. In such cases, physicians should reduce the goal of exercise to whatever level patients believe they can first achieve, with the aim of getting patients accustomed to a habit of doing something physically on most days. Then, the exercise goal can be gradually increased. Motivation can also be increased by exposing patients to the inspiration and support that can be provided by peers.^83,84

Promoting Execution

Even if motivated, lack of goal execution may result from many factors, such as competing priorities, lack of sustained willpower, or lack of know-how in executing behavioral goals. In the face of competing priorities, health goals may also be vulnerable to disregard as a result of the phenomenon of “intertemporal discounting,”⁸⁵ which is the tendency to overvalue goals that are present-oriented (eg, immediate work obligations) while simultaneously discounting the value of goals that are more future-oriented (Fig. 111–13). The more time pressure a person feels as a result of daily obligations, the less likely he or she is to regard the importance of health goals.

For this reason, it is helpful to capitalize on the inspiration provided by a clinical event or office visit by helping patients to anchor health goals with a committed action plan. The health goal should be specific and measurable. The action plan should be detailed rather than vague and involve an action step that will be carried forward as a daily commitment, just as a work goal would. For instance, the desire to start exercising is a vague goal. The intention to join a gym is more specific, but not specifically measurable. By contrast, the commitment to exercise at the gym three times per week provides a specific and measurable goal that can be anchored in one’s daily planning and followed by one’s healthcare team.

Another important means for inducing goal execution is to promote the use of self-monitoring techniques. Self-monitoring serves as an anchor for self-awareness and personal feedback. For instance, overweight individuals who weigh themselves daily are more successful in maintaining weight loss compared to individuals who do not.⁸⁶ Similarly, the use of pedometers promotes physical activity. For example, a review of medical studies found that the use of pedometers was associated with a 27% increase in physical activity compared to physical activity before initiating pedometer use.⁸⁷ Pedometer use was also associated with reduction in weight and systolic blood pressure.

A specific technique that can be used to foster habit intention is the use of implementation intentions. When an individual commits to a new health goal, the new “practice” must be repeated on a daily basis for a period of time before it becomes a habit. Habit formation is desirable because it represents automatic behavior. To strengthen habit formation, Gollwitzer⁸⁸ developed the technique of implementation intentions (Fig. 111–14).⁸⁸ An implementation intention involves the use of an external stimulus to cue a specific behavior. The cue can be a stimulus in time, place, or situation, and the formulation takes the following form: “When it is X, I will do Y,” where X is the cue and Y is the behavior. A large meta-analysis has revealed that implementation intentions are associated with a moderate-to-large effect in stimulating successful goal achievement.⁸⁹

Maintenance

Developing strategies to promote long-term maintenance is essential in promoting successful behavioral change as a result of the high frequency of relapse after the adoption of new health behaviors, such as diet plans and exercise activity. Life events, increasing stress, problems with work-life balance, fatigue, and waning motivation are some of the common factors that may impede long-term goal maintenance. Two central principles in fostering long-term maintenance include developing provisions for ongoing feedback from patients’ healthcare teams and encouraging and providing social support. Social support can be combined with the use of implementation intensions to create “obligation intentions,” whereby individuals feel beholden to honoring their commitments to friends or significant others (see Fig. 111–14).

In addition, it is helpful to have patients develop a contingency plan for maintaining their health goals when stress, competing priorities, or other factors that loosen goal commitment intervene. During such times, the effort should be made to continue with some level of goal commitment rather than completely stop, because complete cessation of activity increases the risk that the health goal will not be reinstituted. For instance, if an individual has assumed a new goal of working out at a gym for 30 minutes each day, the contingency plan may be to reduce the goal to three workouts per week or a shorter walking regimen that can be accomplished without going to the gym.

Long-term management of behaviors also includes recognizing and addressing negative stress and emotional problems, such as anxiety and depression, which are often common in medical patients. The role of the cardiologist in this regard is addressed next.

There are multiple reasons to promote the management of psychosocial risk factors. As previously mentioned, psychosocial risk factors are directly pathogenic, promote adverse health behaviors, and impede adherence to treatment regimens. They also tend to cluster over time when untreated and appear quite commonly in cardiac populations. Psychosocial risk factors such as anxiety and depression are also frequently associated with somatization, and thus may be the underlying cause for chest pain, dyspnea, fatigue, and palpitations.⁹ European guidelines contain specific recommendations for screening and treating psychosocial risk factors in clinical practice,⁹⁰ but to date, only a screening guideline (for depression) has been recommended in the United States.⁹¹ However, physicians can contribute to the management of psychosocial risk factors in a number of ways. Psychosocial interventions within cardiac practice can be organized according to a tiered approach consisting of three basic tiers,⁹ as illustrated in Fig. 111–15.

Physicians can readily screen for the presence of psychosocial risk factors and then decide if any specific factor is something that they can either handle themselves or refer for treatment by ancillary staff or specialists. One approach to screening for psychosocial dysfunction is to use a series of open-ended questions. Open-end questioning often provides rich information and can be readily incorporated into a standard review of systems. Examples of open-ended questions that can be used are listed in Table 111–4. Alternatively, structured questionnaires may be convenient to use if kept brief in nature. To that end, a multidisciplinary council has recommended a stepped screening approach for depression, as shown in Fig. 111–16.⁹¹ The approach is based on the use of the two-item Patient Health Questionnaire, which asks patients to rate how often over the past 2 weeks they have been bothered by: (1) little interest in or pleasure in doing things and (2) feeling down, depressed, or hopeless, with each rated according to a 4-point scale (0 = not at all, 3 = every day). Those who respond positively to either question are recommended to complete the full nine-item version of the Patient Health Questionnaire, which includes additional questions regarding fatigue, sleep, appetite, and suicide risk. Anxiety can also be screened for by using a two-item subscale of the seven-item Generalized Anxiety Disorder scale.

Depending on severity, various psychosocial risk factors may be addressed directly by physicians without referral to staff or behavioral specialists. For instance, patients with mild insomnia may be given tips on how to improve sleep hygiene. For patients who are socially isolated or lonely, the physician can emphasize the need to spend more time with friends and family and/or recommend community-based social programs. Chronic stress is a ubiquitous problem that may also benefit from recommendations that can be made by a physician, including a recommendation to use practical stress reduction techniques (eg, breathing or progressive relaxation exercises) and/or instructional videos or apps for reducing stress.

The physician should also be cognizant of the practical ways in which promoting positive health behaviors may aid in the management of chronic stress. A useful paradigm in this regard is borne out by classic work by Thayer et al.^92,93 They asked experimental subjects to periodically assess their levels of tension and levels of energy and characterize their moods and behaviors during various times of the day. This work revealed that when individuals were both tense and tired (“tense-tiredness”), low mood levels often ensued, accompanied by a higher frequency of “quick fix” behaviors (eg, smoking, watching television, eating sugary snacks) (Fig. 111–17). By contrast, if patients were tense but energetic (“tense energy”), mood levels were substantially better and quick fix behaviors were less common. These data suggest that individuals with higher levels of energy are more resilient to the effects of stress. Physicians can encourage patients in this regard to adopt exercise routines, maintain a healthy diet, and obtain adequate rest and relaxation as a means for managing chronic stress.

The second tier of psychosocial management calls for the referral of patients with greater psychosocial dysfunction to ancillary support staff, such as a physician’s own office staff, or hospital or community programs. For instance, a trained office staff member may be available to aid a patient with moderate stress symptoms by instructing them more fully in muscle relaxation, guided imagery, or diaphragmatic breathing or by teaching behavioral strategies (eg, problem solving, improved goal setting, or instruction in self-monitoring strategies). Alternatively, patients can be referred to structured programs, such as mindfulness-based stress reduction programs or a typically wide array of stress management interventions that may be offered by integrative medicine programs.

The third tier of psychosocial management involves the referral of patients with moderate-to-severe psychological dysfunction to appropriate mental healthcare specialists. For instance, patients who are recognized to be significantly depressed or highly anxious or who have high scores on the Patient Health Questionnaire or Generalized Anxiety Disorder scales should be referred to professionals who treat these psychiatric conditions. In addition, patients may be referred to specialists for other forms of overt psychological problems. For instance, those with high anger can be successfully treated by referral to anger management programs, and recent approaches have also been developed for treating pessimism.⁹⁴ Those with severe sleep problems may be referred to either mental health experts or to organized sleep programs, depending on expertise and problem.

As hospitals organize into larger healthcare systems, the opportunity to align services to provide psychosocial interventions may increase. Preliminary data suggest that provision of tiered behavioral interventions can result in more efficient and effective interventions. For instance, Davidson et al⁹⁵ recently tested the feasibility of a tiered care approach for managing depressive symptoms in a controlled randomized trial involving patients with ACS. This trial compared active stepped care versus conventional care among 150 patients with elevated depressive symptoms following recovery from an ACS. The active care approach, which involved problem-focused cognitive behavioral therapy, delivered by phone or the Internet, and stepped every 6 to 8 weeks, resulted in a greater reduction in depressive symptoms than in the usual care group. This improvement occurred without incurring greater overall healthcare costs in the stepped care group. Accordingly, more trials are indicated to test this type of approach.

A wide variety of psychosocial risk factors have now been consistently linked to cardiac disease. Those most studied have been depression, anxiety, work stress, anger/hostility, poor social support, and low SES. In recent years, additional factors such as insomnia, pessimism, and lack of life purpose have been linked to incidence of CVD and/or cardiac events as well. Psychosocial risk factors exert their effects through both direct pathophysiologic mechanisms and through their negative impact on health behaviors. An important advance over the past decade is the increasing recognition that positive psychosocial functioning is protective of health, as a result of both physiologic buffering and a positive impact on health behaviors.

The management of health behaviors and psychosocial risk factors is interrelated, and improvement in one arena can enhance the other. An increasing number of techniques and tools have been developed to promote patient motivation and assist in the execution and long-term maintenance of new health behaviors, as well as to manage psychosocial risk factors in the context of medical practice. However, to date, there has been relatively modest translation of these interventions into conventional practice, and practical barriers, such as developing more affordable interventions, must still be addressed. However, as a result of the increasing frequency of adverse health behaviors within society during recent decades, and the high concentration of psychological risk factors within medical populations, interest and advances in integrating the management of psychosocial risk factors into the practice of medicine are likely to accelerate.