The ICD Shock and Stress Management Program: Interview with Samuel F. Sears Jr., PhD
- Posted on: 5/3/08
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You are considered a nationally recognized expert on the topic of psychological care and quality of life outcomes of ICD patients; your research in this area is quite extensive. When in your career did you first begin to study the effects of ICDs in patients? What interests you about this area of research? For example, was there a particular case that affected you?
Approximately 12 years ago, I was a new assistant professor in clinical health psychology at the University of Florida Health Science Center and served on the cardiac transplantation team. My responsibilities included performing psychosocial evaluations of candidates to examine their relative strengths and weaknesses related to undergoing transplantation. In the course of these evaluations, I inquired about anxiety and depressive symptoms and current quality of life. At that time, a sizeable minority of patients began presenting with ICDs that tended to be active in terms of shock exposure. In fact, exposure to multiple shocks often triggered an acute need for consideration of all treatment options, including transplantation. The patients and the families were terrified of the shock experience. Their anxieties seemed somewhat reasonable for the situation but still problematic.
These clinical presentations prompted me to work more closely with the University of Florida s EP service. Over time, my colleagues and I compiled some case studies and published a comprehensive review of the literature with some new ideas. We initiated a series of investigations into the point prevalence and the predictive validity of psychological factors in outcomes that have kept us busy ever since. The cardiology journals and community have been very receptive to this research, and we have attempted to lead the way in examining and communicating the patient experience of ICD therapy.
Describe the purpose of the study (including number of patients, age range, etc.). Why was it important to study this population of patients?
The ICD has succeeded in clinical trials to be the treatment of choice for the termination of potentially life-threatening arrhythmias. This is a significant scientific and clinical feat. However, the patient experience of being shocked is notoriously difficult. EP clinics confidently manage the clinical phenomenon of shock, but are often unsure if they have met the patient s other needs related to fear/anxiety about the shock experience.
The ICD Shock and Stress Management Program (ICD-SSMP) was a pilot study designed to examine whether a psychosocial intervention would affect psychological and quality of life functioning in shocked ICD patients. We had a good idea from our clinical practice what seemed to help, but we did not have good data to convince a scientific audience.
How was the ICD shock and stress management program designed? What are some important components to include in such a stress management program?
The ICD-SSMP involved a few key components:
a) ICD-Specific Education: To help patients understand why they have an ICD and why it protects them (e.g., debunking myths about the causes of ICD shocks);
b) Relaxation/Stress Management Training: To assist patients in reducing their ongoing arousal levels post shock (e.g., hypervigilance to shock);
c) Cognitive Techniques: To help patients identify their attitudes and beliefs about themselves, their health, the ICD, and the future (e.g., identify their own personal view of surviving cardiac disease; recognizing the feeling of safety that an ICD could provide); and
d) Group Discussion and Peer Social Support: To allow for the experience and exposure of similar views and feelings about the ICD (e.g., universal experience of shock and living with arrhythmias).
What are some of the common issues/worries that ICD patients face? What are some of the risk factors for poor psychological adjustment to ICDs? In addition, do all ICD patients face anxiety related to their ICD? (If not, what percentage of patients experience ICD-specific anxiety and depression?)
ICD patients and families can present with many different types of worries including, but not limited to, ICD shock, device malfunction, device recall, fears of pain or embarrassment or even fears of death. Some of these concerns can be addressed in a cardiology clinic, while others need to be referred for more extensive psychosocial treatment.
Risk factors for adjustment difficulties have been consistently identified in research and include: young age (< 50 years of age), ICD shock, gender (females), poor understanding of condition and device, pre-morbid psychological difficulties, poor social support or isolation, or more severe or multiple co-morbidities. Collectively, these markers allow for some degree of time triage for clinicians to identify patients likely needing more clinical attention during care episodes.
Furthermore, research has indicated that approximately 13-38% of ICD patients experience anxiety difficulties, and approximately 24-48% of patients experience significant depressive symptoms.
Describe the study results. What were the positives of the ICD-SSMP? Was there any benefit for the patients who participated in only the 1-day workshop?
The good news from this study is that ICD-patient specific psychosocial treatment was associated with desired change in measures of adjustment and functioning, regardless of format. More clearly, ICD patients benefit from attention and strategy building to address their psychological adjustment. Even a biological measure of anxiety, salivary cortisol, was affected. The group treated weekly for six weeks was able to show a more rapid benefit in anxiety, but the differential benefit did not persist in long-term follow-up. Both groups improved on most measures at follow-up. This study has limitations, including the lack of a control group, but its main purpose was to begin a process of empirical examination of this type of specialized psychosocial care in broad health outcomes.
What was unique about this study?
This was the first study to examine a psychosocial intervention in shocked ICD patients using both biological and psychological markers of anxiety.
The study also employed ICD-specific outcomes measures such as device acceptance. Device acceptance is a construct that we have advanced that measures patient adjustment to the ICD via the Florida Patient Acceptance Survey (FPAS). The FPAS allows for a more sensitive measure of post-device functioning than generic quality of life measures or generic psychological adjustment.
Are local ICD patient support groups (such as those hosted at local hospitals) comparable to the ICD-SSMP studied in this article? Do you know if these types of ICD patient support groups have been proven to be helpful, or is more intensive support/treatment needed?
Support groups for ICD patients continue to have value. Support groups are an efficient educational outlet for ICD patients and families to return to living life confidently. I have the privilege of speaking to ICD support groups nationally and internationally. I attempt to bring some of the key elements of ICD-SSMP to these groups. Support groups are limited in that they cannot meet all ICD patient needs all the time. EP clinics that promote ICD support groups are overtly stating that ICD patient adjustment is part of the scope of the care plan. Support groups likely enhance relationships between providers and patients, and deliver information and support that is specific to life with an ICD. This kind of information is not as readily available to patients as you might think in this information age.
What can EPs apply from this research to their current ICD patients? What can they do to help improve reduce patients anxieties and increase patient acceptance, thus increasing their quality of life?
This research was intended to test the value of a rather extensive psychosocial treatment provided by a psychologist and a research team. EP clinics are very busy places, and this type of intervention is not practical for an EP clinic. Nonetheless, the application here for EP is that respect for the patient experience and adjustment level makes a difference. Providing referrals and cultivating other disciplines such as nursing, health psychology, or mental health providers to participate in the care of EP patients makes sense in multiple ways.
What type of future research is needed? Will you be continuing your research in this area?
Beginning this fall, I will be a professor at East Carolina University in both psychology and internal medicine (cardiology), and will continue this type of work. The next level of research and interventions involves increasing the customization of the intervention to target specific groups such as multiple shocked patients, women, or minority groups. Each of these groups may need specific types of content and strategies to optimize quality of life for them. Furthermore, we need some larger size trials for psychosocial interventions. In addition, we need to examine ways to disseminate these interventions via computers, video, etc. to address the larger scale needs. We may also need to examine the inclusion of additional disciplines such as exercise physiology in comprehensive interventions for ICD patients. Clearly, this research area has many important questions to pursue.
Is there anything else you d like to add?
The bottom line with this area of research is to help ICD patients feel safer because of their ICD and aid them in returning to living life with confidence.
More information about this research can be found at: PACE 2007;30:1-7.