The Role of C-L Psychiatrists in Caring for Cardiac Patients

Cardiovascular disease remains a significant public health concern and is a leading cause of death globally despite advances in medical care. Individuals with cardiovascular disease have high rates of psychiatric illness, which is associated with worse health outcomes. The following case describes the role that consultation-liaison psychiatrists play in addressing commonly co-occurring psychiatric illness in the context of cardiac care. Consider this case:

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Ms. G., a 65-year-old woman with a medical history of obesity and type 2 diabetes, is hospitalized due to one month of progressively worsening shortness of breath, fatigue, and leg swelling. Following an initial workup, she receives a diagnosis of heart failure (HF).

After two weeks of treatment in the hospital, Ms. G. continues to experience shortness of breath despite objective improvement in her HF symptoms. She complains of difficulty sleeping and is reluctant to participate in physical therapy. She seems unmotivated and disinterested in her recovery.

The consultation-liaison psychiatry service is consulted to evaluate her for possible depression. Through interviewing Ms. G., the psychiatrist learns that she feels globally disinterested, even in activities that she typically enjoys, such as reading. Ms. G. also describes poor concentration, appetite, and sleep, and she feels fatigued. She acknowledges that her mood is low, and she feels hopeless about her new constellation of medical problems.

Based on these symptoms, the psychiatrist determines that Ms. G. meets criteria for a depressive episode and diagnoses major depressive disorder. Treatment with an antidepressant medication (sertraline) is initiated, and the psychiatrist continues to see Ms. G. regularly throughout her hospitalization to provide support. Over time, Ms. G.’s mood gradually improves, as does her participation in the other elements of her medical care, such as physical therapy. As she prepares for discharge from the hospital, the psychiatrist facilitates follow-up care to ensure continued treatment.

How the Case Was Approached

The case described here highlights several important components of care for patients with psychiatric and cardiovascular illnesses. First, careful diagnostic evaluations are essential, as they help to increase the likelihood of accurate diagnosis and the provision of effective treatments. When evaluating Ms. G., the psychiatrist carefully reviewed the formal diagnostic criteria for depressive disorders to ensure Ms. G. experienced either depressed mood or anhedonia, the duration of depressive symptoms, and the relationship between depression and HF symptoms. Given her multiple physical symptoms, clarifying the time course of Ms. G.’s symptoms was crucial to determining whether her symptoms were related to HF or to an underlying psychiatric illness. Furthermore, distinguishing between her inability to perform an activity due to HF versus her interest in completing the activity helped to clarify Ms. G.’s diagnosis and the likelihood that she would benefit from treatment.

Once a diagnosis of depression is established, initiating treatment is critical, as inadequate treatment of depression has been associated with poor mental and physical health outcomes in patients with heart disease. Though there has been limited study of treatments for depression in patients with HF, both psychotherapy and selective serotonin reuptake inhibitors (SSRIs) are recommended. Cognitive-behavioral therapy improves depression, anxiety, and other aspects of mental health among HF patients with major depressive disorder. Though there is less evidence that SSRIs specifically benefit patients with HF, their safety and efficacy in other patients with cardiac disease (for example, those with coronary artery disease) argues for their use. Possible side effects of SSRIs that should be considered include bleeding, arrhythmias (related to QTc prolongation), and interactions with cardiovascular medications. In the case of Ms. G., sertraline was chosen because of its well-established safety in patients with cardiovascular disease and limited interactions with cardiovascular medications. Given the challenges with treating depression in patients with HF, psychiatrists must be mindful of the need for medication changes and augmentation strategies to manage symptoms.

Psychiatrists also have a role in treating patients who have depression and other cardiovascular illnesses. Depression is clearly linked to both the development and progression of coronary artery disease, and patients with depression following an acute cardiac event (for example, a heart attack) often do not live as long as those without depression. Patients with arrhythmias and those who have undergone placement of implantable cardioverter-defibrillators can develop symptoms of anxiety and even posttraumatic stress disorder, especially if their defibrillator fires.

Finally, those with advanced HF may experience anxiety or depressive symptoms when weighing treatment options (for example, mechanical left ventricular assist devices or transplantation) and may experience delirium when hospitalized for worsening of HF symptoms. Psychiatrists can help to identify and treat psychiatric disorders, manage anxiety related to different treatment options, help patients cope with their cardiovascular illness, and perform capacity assessments to ensure patients can make decisions related to the treatment of their heart disease.

In summary, psychiatrists play a key role in the care of patients with HF and other forms of cardiovascular disease. Identifying depression in patients with cardiovascular disease can be challenging, but accurately diagnosing and treating this illness has the potential to improve both psychiatric and cardiovascular health. ■