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 ?
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)
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.
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