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Patients’ Mental Health a Focus for Primary Care Clinicians

Is it possible to separate the heart from the mind? The answer is “no,” according to specialists who met at the 39th Congress of the State of Rio de Janeiro Society of Cardiology (SOCERJ), an event held virtually in May. During a conference on mental health, physicians and psychologists recalled that long-term data have suggested that people who are under stress are more likely to present with cardiovascular events. Takotsubo cardiomyopathy (TCM) is an extreme example of this.

Several different articles in the scientific literature show how negative emotions affect physical health. According to one of the presenters, Gustavo Barbirato, MD, cardiologist and member of the Department of Spirituality and Cardiovascular Medicine (DEMCA) of the Brazilian Society of Cardiology (SBC), a study performed during the 2006 World Cup in Germany, and published in the New England Journal of Medicine in early 2008, showed for example that viewing a stressful soccer match more than doubles the risk of an acute cardiovascular event.

In contrast, positive emotions have been associated with beneficial effects. Barbirato pointed out that clinical studies have revealed that gratitude, optimism, religiosity, and forgiveness therapy, for example, seem to contribute to a decrease in stress-related risk factors and cardiovascular events. He went on to explain that there are already studies suggesting that this approach may help patients change their attitude toward some diseases (such as hypertension and heart failure) and reduce blood pressure levels. It may also improve treatment compliance. It is important to remember that, despite the benefit of alternative therapies like meditation, mindfulness, and yoga, they do not replace medical or mental health care when they are needed.

Researchers at Harvard University in Cambridge, Massachusetts have been studying the relationship between happiness and longevity since 1938. According to Cláudio Domênico, MD, PhD, clinical cardiologist at the Pro‑Cardiac Hospital, Rio de Janeiro, and moderator of the scientific session, the Harvard Study of Adult Development conducted by Robert Waldinger, MD, and colleagues has shown that a person’s level of satisfaction with their relationships and social connections at age 50 were better predictors of aging than their cholesterol levels were.

Considerations for the Elderly

For Kalil Lays Mohallem, MD, cardiologist and geriatrician at the Pro-Cardiac Hospital, every primary care clinician should investigate two critical aspects in elderly patients: cognitive deficit and depression.

In terms of cognitive deficit, Mohallem recalled that it has already been proven that triage is not beneficial to those without complaints; that is, it is only worth investigating the possibility of a cognitive deficit in those with complaints or when relatives report signs that could indicate a problem.

In terms of depression, however, it is crucial to remember that patients with depression don’t always turn up feeling sad or crying, as Mohallem reminds us. “Patients will often arrive with a physical issue or complaints that are unclear, having been to many appointments to see several different doctors. It is worth investigating these cases,” he emphasized.

He went on to explain that specific tools, like the Geriatric Depression Scale (GDS), could be used for this purpose. Clinicians can also ask patients if they have felt a loss of interest in things they used to enjoy, and if they perhaps feel like they have less energy or can’t face carrying out daily activities. If the answer to any of these questions is “yes,” further investigation may be needed.

According to Lilian Scheinkman, MD, psychiatrist and professor at the Rio de Janeiro State University (UERJ), patients with depression who experience acute myocardial infarction and coronary disease have significantly higher rates of mortality and morbidity. Therefore, clinicians need to look out for this and assess and refer patients to a specialist when needed.

The specialists also highlighted the importance of practicing physical activity, as well as the advantages of taking a multidisciplinary approach. For them, when healthcare professionals with specializations across various fields work as a team, patients can receive comprehensive care, and it is easier to monitor the impact of several drugs, which is particularly important for elderly patients. “All psychotropic and nonpsychotropic drugs each have their own side effects and drug–drug interactions,” said Scheinkman, emphasizing the need for judicious follow-up and individualized treatment plans.

Mental health and cardiovascular health are closely linked, as Natalia Telles, MD, psychologist and coordinator at the Pro-Cardiac Hospital’s Psychology Department explained. “What patient with a heart issue, such as arrhythmia or precordial pain, isn’t going to feel anxious, apprehensive, or afraid of dying?” Telles asked, while emphasizing that the differential diagnosis of comorbidities is an important issue.

Moreover, one factor can increase the risk of another. “We know that a very anxious patient has a higher chance of having a cardiovascular problem, and vice-versa,” she pointed out, reinforcing the need for teamwork to treat these patients. Telles also believes that elderly care is a good example, because it often requires healthcare professionals to be in touch with one another. “It’s the model for how we should be treating patients across age groups,” she said.

Effects of the Pandemic

Domênico explained that, for French social scientist Edgar Morin, the COVID-19 pandemic posed a challenge for humanity: the need to develop a tolerance for the unknown. This is particularly overwhelming, since we live under the illusion that we have control, he said.

Although we don’t really have control over things, this illusion helps us be better organized and disciplined. “The pandemic came to destroy this illusion,” said Scheinkman.

Telles added that the uncertainties imposed by the novel coronavirus “put life on hold.” By that, she meant that desires and motivation were put on hold and people’s lives became increasingly restricted.

In turn, this impact on social life has an impact on mental health, especially with regard to a rising number of cases of compulsive eating, alcohol and drug use/abuse, depression, panic disorders, and insomnia.

Scheinkman also noted a significant daily increase in the search for professional help in the form of psychiatric and mental health care. “I think there was a significant increase in how much people suffered,” she said, adding that two groups particularly affected by the pandemic were the elderly and adolescents.

Another issue that became more prominent during the pandemic was burnout. “Work invaded the home, so that period between going to work and then leaving work behind at the end of the day ceased to exist,” said Telles. She went on to point out that the challenge was even more significant for healthcare professionals.

Mohallem emphasized the importance of primary care clinicians being aware of their own health. “We have to take care of our own mental health. I can’t look after other people if I don’t take care of myself,” he said.

This article was translated from the Medscape Portuguese edition.

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