European Heart Journal Advance Access originally published online on November 19, 2007
European Heart Journal 2007 28(24):2964-2966; doi:10.1093/eurheartj/ehm522
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Does every cardiologist need a psychologist?
Post-doctoral Researcher, Scientific Research Foundation (FWO-Vlaanderen), Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, 3000 Leuven, Belgium
* Corresponding author. Tel: +32 16 33 69 81; fax: +32 16 33 69 70. E-mail address: fabienne.dobbels{at}med.kuleuven.be
This editorial refers to ‘Psychological treatment of cardiac patients: a meta-analysis.’ by W. Linden et al., on page 2972
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. 
It is well known that emotional factors and chronic stressors increase the risk for and outcome of cardiovascular disease. Emotional factors refer to affective problems such as depression, anxiety, anger, and hostility. Chronic stressors encompass low social support, low socio-economic status, work-related stress, and marital stress.1 Adverse outcomes may occur through interactions of these factors with physiological factors such as the central nervous system and the hypothalamus–pituitary–adrenal axis, metabolic abnormalities, inflammation, insulin resistance, or endothelial dysfunction. Another, perhaps equally important pathway may be through the interaction with other behavioural factors such as non-compliance with prescribed medication, physical inactivity, or smoking. The exact role and importance of these mechanisms, however, need further investigation.1
Following the increasing understanding of the importance of stressors and emotional factors, and primary or secondary prevention of cardiovascular events, research has begun to examine the impact of psychopharmacological and psychotherapeutic interventions. It was hoped that successful treatment of these factors may have a spin-off favourable effect on cardiovascular morbidity and mortality. Currently, psychosocial interventions are embedded in most guidelines for cardiovascular rehabilitation, but are usually based on consensus.2–4 A strong evidence base, coming from solid meta-analyses, however, was lacking in isolating the benefits on mortality and morbidity in patients with established cardiovascular disease that are solely attributable to psychological interventions. Moreover, gender differences in outcomes were not taken into account and a distinction between short- and long-term benefits has usually not been made. Based on a meta-analysis of available studies, Linden et al. concluded that psychological treatment reduced mortality of cardiac patients by 27% for at least the first 2 years after a cardiovascular event5. Event recurrence was reduced by 43% at follow-up >2 years. Successful reduction of stress was necessary for mortality benefits to occur. Moreover, only psychological treatment initiated at a minimum of 2 months post-event produced a significant benefit in survival, while interventions starting earlier in the disease course did not yield a significant effect.5
As with all meta-analyses, a word of caution is needed when reading this analysis. First, the authors only report odds ratios. These may mask the actual absolute risk reduction. In an earlier meta-analysis published in the Cochrane database,6 the absolute risk in the treatment group was 8.6% and in the respective control groups 9.2%. This did not reach significance. Based on these mortality data, an odds ratio of 0.8 in the present meta-analysis means a mortality reduction from 9.2 to 7.4%. This is a small, but clinically reasonable risk reduction.
Furthermore, there are some technical issues with the report: the authors do not explain why a cut-off of 2 years was used to scrutinize cardiovascular outcomes. The analysis is puzzling in that the authors report no mortality benefit beyond 2 years, whereas there is clearly a strong effect on morbidity. The study may have been underpowered (i.e. too few deaths) to come to firm conclusions in terms of mortality. Secondly, the cut-off of 2 months used in distinguishing early and later onset of psychological treatment has not been validated against other cut-offs. Hence, this cut-off seems somewhat arbitrary. It is indeed likely that spontaneous recovery from the psychosocial stress related to disease onset occurs within the first 2 months. Yet, while it is acceptable that the authors selected this cut-off as most Canadian patients enter cardiac rehabilitation programmes at 
2 months post-event, this does not necessarily reflect common rehabilitation practices in Europe. In Belgium for instance, patients enter out-patient rehabilitation typically 14 days after percutaneous coronary intervention, 1 month after acute myocardial infarction, and 6 weeks after coronary artery bypass or valve replacement surgery. As such, the psychological intervention would always be initiated within 2 months of the event. Finally, the absence of a graphic display of the data is unfortunate. It is difficult to obtain insight into the heterogeneity of the data, which is clearly present. These remarks, however, do not minimize the scientific quality and the rigorous conduct of this meta-analysis, and the clinical relevance of its findings that psychological treatment is capable of reducing mortality and mortality in patients with cardiovascular disease.
Perhaps the most interesting and somewhat surprising finding of the meta-analysis is that no mortality benefits for women were observed in the short- or long-term follow-up. Before discussing this further, the reader should be warned that the subanalyses are only suggestive and lack the statistical power to draw firm conclusions at this stage. In fact, in breaking down the studies into those studying gender effects, none of the differences reached significance and even the main effect of psychological interventions on mortality within 2 years was no longer significant. These subanalyses should therefore be treated with caution and may leave the reader confused. Nevertheless, gender differences in prevalence, risk factor profiles, and outcomes of cardiovascular disease have recently gained more attention in the literature. It is common knowledge that women develop cardiovascular disease on average 10 years later in life. Once women have the disease, their prognosis is worse than that of men, even when controlling for age differences. Hypotheses as to why female patients do not experience a survival benefit from psychological interventions could be the following: first, the prevalence of major depression is twice as high in women and the depressive symptoms are more severe. In addition, women report lower levels of social support and higher marital stress after cardiac events than men.7 Because of their more complicated psychosocial risk factor profiles, longer psychotherapy treatment and a combination with antidepressant treatment may be indicated in female patients. Secondly, men and women also differ with respect to coping mechanisms. A meta-analysis showed that women minimized the impact of the disease, tended to delay seeking treatment, and did not want to bother others with their health problems.8 This may clearly put them at risk for adverse outcomes, even after successful treatment of their emotional disturbances or stressors. Similarly, other gender differences in cardiovascular risk factors exist, with women being less physically active, and more likely to be obese than men.9 Moreover, women participate in cardiac rehabilitation programmes less frequently. This may be due to the higher susceptibility of women to depressive symptoms, and a greater burden of co-morbid disease. All these factors together may render female patients at a higher risk for poor cardiovascular outcome.
The authors correctly concluded that a relatively small investment in psychological treatment can lead to clinically meaningful reductions in mortality and morbidity. Screening for distress throughout the recovery and rehabilitation period should be performed, and psychological treatment should be offered to those with continued adjustment problems for months after the critical event. Forms of psychological treatment included in the present study were either psychotherapy, such as, for example, behavioural or cognitive–behavioural therapy, and therapies referring to relaxation and self-regulation. Yet, the term ‘psychological treatment’ is used as an ‘umbrella term’ and a clear definition is lacking. While every physician may have a basic understanding of the content of relaxation training, the term psychotherapy is often bewildering, caricaturized, and more difficult to describe in terms of sound bites. To increase the likelihood that the results of this meta-analysis are indeed translated into changes in clinical practice, i.e. screening of distress and referral to psychological treatment when indicated, a definition of psychotherapy or psychological counselling may be helpful. Psychotherapy is a way of treating mental or emotional problems, predominantly by talking about the condition and related issues with a mental health professional. Through psychotherapy sessions, patients may learn to find better ways to cope and solve problems, and learn to identify and change behaviours or thoughts that adversely affect their lives.
Ideally, psychological interventions are part of multidisciplinary cardiac rehabilitation programmes.2–4 Yet, the results of the present meta-analysis stimulate the delivery of psychological interventions in overall cardiac practice, especially because only a minority of patients are referred to rehabilitation programmes10 and because multidisciplinary rehabilitation programmes are typically provided for a short period of time. If cardiac rehabilitation teams are not available, the cardiologist or a member of his/her team should screen for psychological morbidity or risk factors and refer patients at risk to mental health professionals. The National Heart, Lung and Blood Institute, for instance, recently recommended the Beck Depression Inventory (BDI) as an easy to use screening instrument to assess the presence and severity of depressive symptoms.11 Consensus on the use of additional screening instruments to assess stressors and emotional risk factors is urgently needed. Because of the detrimental impact of psychological factors on cardiovascular morbidity and mortality on the one hand, but the proven efficacy of psychotherapy to prevent poor outcomes on the other hand, a psychologist should be a necessary partner in state-of-the-art cardiological care. Specific attention should be paid to the development of psychological treatment programmes for female patients in order to meet their unique needs.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
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