Magic

There is often magic created right on top of our heads through the most innocent things we do and sadly enough we remain oblivious. So, once in a while, look up in worship and you might just be delighted! – RP13262438_10157003627285381_187428694_o RP

Creative to Academic – Shifting Focus

My Uni life is pushing me to write ‘academic’, though I don’t like it much I did like this attempt. Posting it just to come back and read it sometime later…

Biomedical or Behavioral ?

Objective

The Australian Charter of Healthcare Rights describes ‘seven rights of patient’ which enables the healthcare workers and the patient to partake equally in treatment and recovery course. These rights ensure delivery of safe and high quality healthcare, whenever and wherever (Australian Commission on Safety and Quality in Health Care, 2009). This critical review paper would discuss whether the rights, ‘respect’ and ‘participation’ are better achieved through biomedical or behavioral/ psychological interventions when managing anxiety in Coronary Heart Disease (CHD) patients. It would be evaluating how these interventions are taking into consideration patient’s rights, under discussion, based on evidences from research studies.

Anxiety and CHD

Several studies have indicated that anxiety is a serious risk factor which contributes to the developing of CHD. Anxiety is “characterized as a strong negative emotion with a component of fear and is associated with perceptions of unpredictability, accompanied by a marked apprehension concerning the future” (Kubzansky et al., 1998, p. 47).  It is potentially cardiotoxic and its manifestation results in low quality of life, worsened functional status, negative illness perceptions, increased disability and physical symptoms in CHD patients (AIHW, 2014; Foxwell, Morley, & Frizelle, 2013; Kubzansky, Kawachi, Weiss, & Sparrow, 1998; Martens et al., 2010).

It is suggested that anxiety influences the health behavior of CHD patients. An anxious patient becomes highly dependent and constantly worried about health. Anxiety also influences patient’s choices. Recurrent and persistent anxiety can pose threat of ‘emotional paralysis’ rendering the CHD patient impaired of psychological and physiological functioning. In fact, even after receiving successful treatment, CHD patients continue to exhibit anxiety symptoms and sometimes to larger degrees due to fear. This adds on further risk of mortality, unstable angina and myocardial infarction (Blumenthal, Thompson, Williams, & Kong, 1979; Ginting, Näring, & Becker, 2013; Kubzansky et al., 1998; Riegel, 1989).

Hence, interventions to manage anxiety must make an integral part of comprehensive CHD management in patients suffering from this mental condition (Martens et al., 2010). However, the choice of intervention, whether biomedical or behavioral, either alone or integrated must be taken considering patient’s safety, personality, conviction and choice while ensuring effectiveness. Investing time on understanding patient’s personality through extensive clinical interviews will help the health professional make the best choice (Sirois & Burg, 2003)

Managing Anxiety – Biomedical and Behavioral/Psychological Interventions

(a) Biomedical Interventions

The effective drugs choices for anxiety are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Studies prove biomedical intervention to be effective. It starts showing positive outcomes in a short span of time; however, there are a few points of concerns. Though these drugs have no known cardiotoxicity, possible pharmacokinetic interactions cannot be ruled out as CHD patients are under antihypertensives, hypolipidemic and antiarrhythmic drugs (Davies, Jackson, Potokar, & Nutt, 2004; Ravindran & Stein, 2010). In addition, it is studied that inherently anxious patients respond to medical treatment inadequately (Ginting et al., 2013). This observation is in agreement with the conclusion notes made by Ravindran & Stein (2010). In their review paper on pharmacologic treatment of anxiety disorders they noted that, “despite notable advances, many patients with anxiety disorders fail to adequately respond to existing pharmacologic treatments” (p. 839).

The inadequate response to pharmacological treatment is explained by Ginting et al. (2013), in their study of anxiety associated attentional bias in CHD patients. Their study indicates that CHD patients exhibiting anxiety tend to develop preconditioned mindset due to their previous experiences and beliefs and instead of believing the benefits of medication may rather worry about its side effects. Strong anxiety hence leads to generalization and specific hypervigilance and it is assumed that this “might lead to poorer information processing and poorer medical decision making” (Ginting et al., 2013, p.1318). This claim is supported by the review paper by Foxwell et al. (2013) which examines the relationship between illness perceptions, mood and quality of life in CHD population. They stated that, “poorer illness understanding, perceiving greater negative consequences and low personal and treatment control had the strongest relationship with elevated anxiety and depression across CHD populations” (Foxwell et al., 2013, p. 219). Another particular concern with biomedical intervention is its ‘disorder- specific’ approach. The existing understanding of the biology of such mental condition is limited. The failure to trace molecular origin of a mental condition, like that of anxiety, makes the approach inept (Deacon, 2013).

Based on theses evidences, it is safe to assume that anxiety in CHD patient engenders lack of control over treatment. Due to the nature of negative emotions that anxiety is associated with, treatment course must target patient’s ‘anxious character’. Hence, the approach must be ‘patient-specific’ rather than ‘disorder- specific’. While it is agreeable that the drug prescriptions are made after careful assessment and consideration; it is debatable if biomedical intervention can be tailored for each patient. It is also arguable if the approach can consider patient’s circumstances, environment, cultural aspects and needs, both physical and emotional.

(b) Behavioral/ Psychological Interventions

Over the last century, behavioral therapy approaches to manage anxiety and related mental condition have gained popularity owing to beneficial and safe outcomes. Researches related to interventions such as exercises, mindfulness meditation, music therapy, psychotherapeutic and psychological interventions have been conducted which provides qualitative and quantitative evidence to prove the effectiveness of behavioral interventions (Bradt & Dileo, 2009; Merswolken, Siebenhuener, Orth-Gomér, Zimmermann-Viehoff, & Deter, 2010; Oldridge, 1982; Parswani, Sharma, & Iyengar, 2013; Reid, Ski, & Thompson, 2013). However, most of the studies mentioned cases of drop outs during intervention process. Owing to the characteristics of anxiety as described in the works of Foxwell et al. (2013) and Ginting et al. (2013), constant reinforcement of treatment benefits and adjusting the course and method of treatment becomes necessary. It is to be noted that patient compliance with a health changing behavior is shown only when the potential benefit becomes apparent (Oldridge, 1982).

Ginting et al. (2013), in their conclusion remarks, strongly recommend Cognitive Behavior Therapy (CBT) as an effective treatment of choice. CBT allows people to evaluate their perception about common difficulties and helps them to modify thought patterns and choose their reaction to situations (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). The goal of CBT is “symptom reduction, improvement in functioning, and remission of the disorder” (Hofmann et al., 2012, p. 428). CBT recommendation is supported by the earlier work by Dao et al. (2011). The study showed that cognitive behavioral intervention were the most feasible and acceptable intervention for symptoms of preoperative anxiety.  Furthermore, this model is in sync with the Healthcare Rights charter because “in order to achieve this goal, the patient becomes an active participant in a collaborative problem-solving process to test and challenge the validity of maladaptive cognitions and to modify maladaptive behavioral patterns” (Hofmann et al., 2012, p. 428).  In a similar work by Lie, Arnesen, Sandvik, Hamilton, & Bunch (2007), quantifiable benefits of structured informational and psychological home based intervention program on surgery patients is recorded. Another recently popular and effective intervention is ‘talk therapy, which also forms the base of all psychotherapeutic methods like CBT or any other structured psychological intervention (Dao et al., Deacon, 2013; 2011; Ginting et al., 2013; Hofmann et al., 2012; Lie et al., 2007).

Hence, we see that the aspect of respecting patient’s being and helping them rebalance is reiterated in behavioral/ psychological interventions. Personalized interventions based on CBT can be planned encouraging participation. Also, the therapy can be made patient centric and tailored to achieve positive outcomes.

(c) Going beyond

Going a step further, in one of their review papers Reid et al. (2013) recorded improved benefits upon including patient’s partners. The objective of the study “was to systematically review evidence on the effectiveness of psychological interventions for patients with CHD and their partners” (p. 1). The most commendable aspect of this study is that it looks at anxious CHD patient care in holistic sense. It respects the fact that answers to anxiety reduction does not lie in isolating the patient and addressing it alone. The study also indicates benefits to partners as they generally found to have greater levels of emotional distress and anxiety than patients. This is also recorded by Riegel (1989), in her work on social support for such patients. Her article lays emphasis on the concept of social support but interestingly, she clarifies that social support of any form can generate negative feelings if it is not desired by the patient and if it is not meant to enhance their well-being. Hence, a reliable support as per patient’s preference can go a long way in making the intervention process better. The sense of having someone along in their journey of life, keen to participate in their activities is assuring and builds confidence.

Another novel viewpoint presented by both Ginting et al. (2013) and Ravindran & Stein (2010) through their studies, is research focus on systematizing pharmacologic and using combined pharmacologic-psychosocial strategies. Deacon’s, (2013) research too supports combining treatments; however, he specifically encourages synergy and compatibility of treatment. Again, this requires knowledge of treatment mechanism and most importantly, understanding of individual condition and preferences. The future dwells in “determining which parts of multi-component treatments are most beneficial and identifying optimal matches between patient characteristics and specific components of interventions” (Sirois & Burg, 2003, p. 98)

Conclusion

A large part of disease management lies in patient’s own conviction, more so in mental conditions like anxiety. In essence, this may also explain the inadequate response of anti-anxiety medicines in CHD patients, in spite of medication adherence. Suggestive of the fact that patient-compliance is not necessarily patient-participation. In the same way, though behavioral interventions render no side effects and are non-addictive, they have not been proven successful all the time. For someone who believes that only pills can manage his disease condition may not be benefitted completely by behavioral intervention. In such situations, alongside medication, interventions like talk-therapy can be of great use which will help us analyze the ‘why’ of the issue. This may also allow the patient to see his/her condition with a clearer perspective and novel coping strategies can be developed together which the patient believes in. The importance of communication, social support and building confidence cannot be understated.

Based on the evidences, behavioral/psychological interventions look much favorable keeping the patient’s rights in mind. However, one cannot overlook at the immediate relief the biomedical intervention brings in. Hence, a ‘patient-centric-integrated approach’ which orients more towards behavioral/psychological interventions, will be best suited. This could be formulated keeping the patient’s anxiety characteristics in mind. The aspect of ‘patient-centricity’ reflects the values of respect and participation and the aspect of ‘integration’ reflects the intent of therapy being effective. However, the interventions chosen must be compatible, must exhibit synergism and must focus on dealing with the ‘why’ of the issue rather than the ‘what’. The overarching principle of treatment being patient-centric will make him/ her feel genuinely cared for.

References

AIHW,.(2014). Cardiovascular disease, diabetes and chronic kidney disease: Australian facts mortality. Cardiovascular, diabetes and chronic kidney disease series no. 1. Cat. no. CDK 1. Canberra: AIHW.

Australian Commission on Safety and Quality in Health Care,. (2009). Australian Charter of Healthcare Rights: A guide for healthcare providers. Sydney NSW.

Blumenthal, J., Thompson, L., Williams, R., & Kong, Y. (1979). Anxiety-proneness and coronary heart disease. Journal Of Psychosomatic Research, 23(1), 17-21. doi:10.1016/0022-3999(79)90066-7

Bradt, J., & Dileo, C. (2009). Music for stress and anxiety reduction in coronary heart disease patients.The Cochrane Library.

Dao, T. K., Youssef, N. A., Armsworth, M., Wear, E., Papathopoulos, K. N., & Gopaldas, R. (2011). Randomized controlled trial of brief cognitive behavioral intervention for depression and anxiety symptoms preoperatively in patients undergoing coronary artery bypass graft surgery. The Journal of thoracic and cardiovascular surgery142(3), e109-e115.

Davies, S. J., Jackson, P. R., Potokar, J., & Nutt, D. J. (2004). Treatment of anxiety and depressive disorders in patients with cardiovascular disease.Bmj328(7445), 939-943.

Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research.Clinical Psychology Review33(7), 846-861.

Foxwell, R., Morley, C., & Frizelle, D. (2013). Illness perceptions, mood and quality of life: A systematic review of coronary heart disease patients. Journal Of Psychosomatic Research, 75(3), 211-222. doi:10.1016/j.jpsychores.2013.05.003

Ginting, H., Näring, G., & Becker, E. (2013). Attentional bias and anxiety in individuals with coronary heart disease. Psychology & Health, 28(11), 1306-1322. doi:10.1080/08870446.2013.803554

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses.Cognitive therapy and research, 36(5), 427-440.

Kubzansky, L., Kawachi, I., Weiss, S., & Sparrow, D. (1998). Anxiety and coronary heart disease: A synthesis of epidemiological, psychological, and experimental evidence. Annals Of Behavioral Medicine, 20(2), 47-58. doi:10.1007/bf02884448

Lavie, C., & Milani, R. (2004). Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training. The American Journal Of Cardiology, 93(3), 336-339. doi:10.1016/j.amjcard.2003.10.015

Lie, I., Arnesen, H., Sandvik, L., Hamilton, G., & Bunch, E. H. (2007). Effects of a home-based intervention program on anxiety and depression 6 months after coronary artery bypass grafting: a randomized controlled trial. Journal of psychosomatic research62(4), 411-418.

Martens, E. J., de Jonge, P., Na, B., Cohen, B. E., Lett, H., & Whooley, M. A. (2010). Scared to death? Generalized anxiety disorder and cardiovascular events in patients with stable coronary heart disease: The Heart and Soul Study. Archives of General Psychiatry67(7), 750-758.

Merswolken, M., Siebenhuener, S., Orth-Gomér, K., Zimmermann-Viehoff, F., & Deter, H. C. (2010). Treating anxiety in patients with coronary heart disease: a randomized controlled trial.Psychotherapy and psychosomatics, 80(6), 365-370.

Oldridge, N. B. (1982). Compliance and exercise in primary and secondary prevention of coronary heart disease: a review. Preventive Medicine, 11(1), 56-70.

Parswani, M. J., Sharma, M. P., & Iyengar, S. S. (2013). Mindfulness-based stress reduction program in coronary heart disease: A randomized control trial.International journal of yoga, 6(2), 111.

Ravindran, L. N., & Stein, M. B. (2010). The pharmacologic treatment of anxiety disorders: a review of progress. The Journal of clinical psychiatry,71(7), 839-854.

Reid, J., Ski, C. F., & Thompson, D. R. (2013). Psychological interventions for patients with coronary heart disease and their partners: a systematic review. PloS one, 8(9), e73459.

Riegel, B. (1989). Social support and psychological adjustment to chronic coronary heart disease: Operationalization of Johnson’s behavioral system model. Advances in Nursing Science11(2), 74-84.

Sirois, B. C., & Burg, M. M. (2003). Negative emotion and coronary heart disease a review.Behavior modification27(1), 83-102.

Nights and truth!

There is something about the dark… nights rather. It is amusing to note that a time when people are the most true to themselves is not in the shine of daylight but the darkness of night. Lust, vengeance, fear, all these emotions have same color… dark! It must be that the energy in the day light that purifies most of the night’s sins. Otherwise, world would have sunk in it.

Contradictions if you noticed, people are true to themselves in dark hours. Energy of the daylight purifies most of it. Truth is hence black, not white!

My love and bargain relationship with a Chemical

This is a small story of my love to a chemical. A few years back I had developed an amazing love for general anesthetic. It may have different scientific names but for me it was my sleep drug which I used to bargain my memories with.

I have lived a good 33 years of my life in a country which is one of the most populated. Though crowded and busy, it is one of the countries which is reasonably advanced in medical sciences, at least towards urban areas. The sad part however is that, once a common man turns a patient, he may be at mercy of many. He will have to let go of his wallet for sure. He may also have to let go of his dignity; for only almighty knows which procedures he will have to undergo, what circumstances he may be in and how many callous people he will end up encountering during the treatment period. In general, the medical fraternity there lacks empathy. This I am saying not a hearsay or notion but as an experience because I am a victim of compassion-less treatment. I may not represent everyone, this may be generalization, I agree but I had to write about it someday. Sadly enough, when empathy is removed from the ‘patient’ and ‘medic’ relationship, what remains is a ‘body’ and ‘mechanic’. You cannot expect a mechanic to be compassionate towards the broken car he is fixing. On the contrary, I suppose that’s not the right comparison, mechanics do have love their machines.

I was reading up an article called “Maintaining patients’ dignity during clinical care: a qualitative interview study.” It says, “Dignity is a core concept in nursing care and maintaining patients’ dignity is critical to their recovery. In Western countries, measures to maintain dignity in patients’ care include maintaining privacy of the body, providing spatial privacy, giving sufficient time, treating patients as a whole person and allowing patients to have autonomy. However, this is an under-studied topic in Asian countries.” More than any part, I agree with the last one. Yes, it is a rather under-studied and under-practiced topic in Asian countries. The reason again is obvious, there are ‘many’ to be taken care of… and the carers are not taken care of either.

A few years of my life I have lived as non- regular ‘patient’. Being a woman added on to the misery. I am educated and had more than average understanding of science, yet there are episodes I can recollect vividly which made me feel as an experimental guinea pig on a medical practitioners’ desk. I can imagine what would be happening to those who have no voice at all. My experience tells me that lack of compassion runs mostly at lower levels. Doctors are often fine and treat their patients as ‘another human being’ who is in charge of his body and immediate environment. I am assuming many factors influence the behavior of the other medics. Whatever, the case may be, every episode of ill treatment during a procedure remains as a sore memory in somebody’s mind. It can reach levels of paranoia, when one no longer wants to go for any medical procedures and disgusts hospitals but what can one do when there is no other option.

As I was saying, sometimes you know that there is no other option. You have to undergo a procedure you are not sure of and you don’t know how the medics are going to be in the unfortunate ward you will be shifted in. After undergoing a couple of procedures I felt that the trauma a few left behind was terrible. For days, I would feel bad and recollect all the faces I saw in the room. I would tell myself that for them I was just another patient, I wouldn’t be recognized if they see me outside. Then once, during one of the procedures for the first time I was given general anesthesia. General anesthesia is a treatment with certain medicines that puts you into a deep sleep so you do not feel pain during surgery or any procedure performed on you. When you receive these medicines, one is not aware of what is happening around. I used to remember falling asleep and waking up. The rest never occurred. It gave me a sense of false assurance. Since then, every time I heard of procedure, my first question to the doctor would be, “Will you make me sleep?” A ‘yes’ to that questions was so comforting. Though, I knew the ill effects of general anesthesia, I was alright to bargain. I fell in love with that full syringe of anesthetic. I would choose a drug against my memory but again, it was not as per my whims and fancies.

There were more episodes, a few traumatic. I wanted them to end. Thankfully for me, I could I finally make a choice and exit. Now it’s past, but however the fact that I am writing about it itself tells me that it haunts but that drug, I will love it always.

The lesser felt Gain

I wonder if this is the truth of life… I have noticed that the feeling of loss is more ‘felt’ than the feeling of gain. As in, whenever we gain something in life, may it be a new job, or excellent grades, a new house or even a new relationship, it doesn’t alarm us. Gains usually sink in. It just sinks into us and we take it as a part of our lives, something which was meant to be. One never really feels it the way it needs to be felt. Some don’t want to, they fear celebrating gain may make them loose it to soon or bring in a bad omen. People just don’t feel gain with all the happiness and joy that it commands; they think they deserved it, always.

At the same time, loss is alarming, usually a shock, unexpected mostly. It slaps you on your face and your entire being goes resisting it. They are harsh and more painful.  What can be accounted as loss? Losing a job, not making it to an interview after three successful rounds, missing a flight, a sudden death of someone close, a break up mail…You think about it, rebel, and spin a story of how it’s all wrong and such a thing cannot happen to you. In fact, losses remain in your memory engraved much deeper than gains.

This natural human conduct stems from the eternal desire for self preservation. Self preservation somewhere has to do with a certain amount of selfishness. We like to think that a little more for me will do no harm. All that I have got and will get is what I deserve, and I do not deserve loosing anything.

Inherent selfishness you may call it; human beings seek only to satisfy their own needs, motivated solely by personal interest. In economics, this mental model even has a name, it‘s called homo economicus–that defines man as a being whose production and consumption is motivated entirely by his own material gain. This was the basis for the theory of ‘rational choice’, which affirms that ‘rational’ people will always choose what benefits them, even at the expense of others. However, what makes this choice seem natural to some cultures is not its rationality, but rather the fact that the process of acculturation and socialization from early childhood makes this their first reaction. People raised in other cultures will not necessarily have the same inclination.

Again, loss pinches you only when we lose something which we so dearly were hanging on to. No one would be shocked or alarmed loosing something they always wanted to get rid of. One will be rather happy, getting rid of it/ them naturally. That is gain in fact; gain of so called peace. Self preservation again…

Going a bit deeper… The human race boasts of cooperation and altruism. Even those in its real sense are ‘Selfish’. Ponder on that!