OP. EXP. 5. GESTIÓN DE CAMBIOS

Patients need to understand the typical emotional responses to an acute cardiac event. It is usual for patients to pass through a period of anxiety after their acute event499–504_,

especially upon transfer to the ward and on discharge from hospital505_{. Common}

concerns include a fear of death, a further cardiac event, physical disability and unemployment. Physical symptoms such as palpitations, breathlessness and chest pain may be caused by anxiety, although patients may not recognise such symptoms as manifestations of anxiety. Anxious patients usually have little concentration and often fail to comprehend, accept or recall information provided in hospital305,307_.

Further, anxiety may lead to a delay in resuming activities.

Depression is also common after an acute cardiac event360,493,502 _{and has been}

associated with increased mortality and morbidity358,506–509 _{and increased costs}

associated with rehospitalisation510_{. In most cardiac patients, such depression is more}

a grief or bereavement reaction rather than a depressive illness511,512_{. It is best referred}

to as a “depressed mood” in which a sense of real or imagined loss is experienced. Symptoms are mostly mild and transient and their manifestations are usually subtle. A depressed mood may be experienced first in hospital. However, it typically peaks during convalescence513_{. Common symptoms of a depressed mood include an}

inability to concentrate, restlessness, disturbed sleep, early waking, irritability, a sense of fatigue, loss of interest and motivation, sentimentality or even tearfulness. Patients may become pessimistic about their recovery and fearful of a recurrence. Fatigue and weakness may be equated by them with heart damage greater than anticipated504_.

They may then become preoccupied with the supposed limitations of the illness. Withdrawal and irritability during convalescence are frequent symptoms of a depressed mood. Concerns are increased if there is awareness of heart action, ectopic beats or palpitation, non-cardiac or cardiac chest pains, breathlessness from

hyperventilation or unfitness or of any other symptoms of physical and

psychosomatic origin. It is important to explain and discuss such symptoms during group sessions. Forewarning patients that a depressed mood commonly occurs during convalescence can also be most valuable. Anxiety and depression often co- exist513_{. Several symptoms, including irritability, reduced concentration and sleep}

Patients may cope with their anxiety, depression or other symptoms by denial, convincing themselves that any problems they have are not serious and that they are not at risk of future problems. While denial may be a useful defence mechanism in the short-term for coping with anxiety and a depressed mood514 _{it can exert a negative}

influence upon outcomes if patients cease to adhere to regimens regarding lifestyle, medication and other advice515_.

It is usual for anxiety and depression to decrease spontaneously during the months after the event342,349,516–518_{, although they may persist for up to a year or more}36,501,502,519_.

Studies suggest women have poorer psychological outcomes than male patients520–524_.

Early detection and management of psychological difficulties can prevent persisting disturbances. Facilitators of group sessions need to identify those at risk of continuing psychological problems and, if necessary, refer them to appropriate team members for individual assistance. Psychological difficulties persisting for several months are usually attributable to an unrecognised and untreated depressed mood520,525_{, which can lead to}

nonadherence with advice, occupational difficulties, and marital and sexual dysfunction309,360,385,507,520,526_{. Moreover, as already stated, depression is a powerful}

predictor of mortality after acute myocardial infarction527–529_{. A further loss or crisis can}

intensify or prolong the depressed mood530_{. In some patients, the onset of depression may}

be delayed531_{. In these cases, the acceptance of loss and the need for change have usually}

been denied earlier. Those who do not display some signs of depressed mood early will often become depressed at a later stage of their recovery530,532_.

Psychological responses can be effectively addressed during group sessions by a skilful facilitator. When patients are able to disclose feelings during group sessions, identification with others who are experiencing similar problems can be a major benefit7,309_{. Recognition that problems are not unique is reassuring}7,533,534_{. Facilitators of}

group discussions should explain that anxiety and a depressed mood are typical after acute cardiac events but that they are usually mild and transient. Fear of further cardiac episodes, anxiety about resuming work and concern about overprotectiveness in spouses may be successfully shared with others in the group. In addition to

identifying with others who have similar problems, patients also gain from observing positive changes and a rapid recovery in others7,309_{. Thus, a group should ideally}

contain patients at all stages of recovery, including “elders” who often adopt a preceptor role for the newer group members. Discussion groups for patients can also benefit from the occasional attendance of former patients who have made a

favourable adjustment. The practice of introducing successfully rehabilitated post- surgical patients to those awaiting the operation is based on the same premise. Small groups of about six to eight are more effective than large groups for uncovering more complex emotions and concerns of patients and spouses. Where possible, small group discussions should be available as adjuncts to the larger education and

counselling sessions. It is preferable for small group discussions to be facilitated by a social worker, psychologist or other qualified counsellor with appropriate training.