As director of behavioral health for the Texas Health Springwood Center Southwest Fort Worth, Ramona Osburn, MBA, is passionate about the adult cardiac intensive outpatient program that began Oct. 1, 2008.
"It's important to know people who experience an MI and suffer depression have a 3-4 times greater risk of dying within 6 months than those who aren't depressed," she said. "They don't consistently take their medications, they don't make healthy changes to their diets and they don't exercise. There's a significantly higher risk of suicide in this population as well."
Pat Paprocki, RN, cardiac rehab program coordinator at Harris Methodist HEB Hospital, Bedford, TX, is pleased to have a resource available for patients in her program who demonstrate signs and symptoms of depression.
"We provide three sessions a week for 12 weeks, allowing nurses to establish trusting relationships with our patients," she explained. "All of our patients are screened by an RN during an initial assessment that includes questions around current signs and symptoms of depression, as well as any personal history of depression."
The screening continues through the 12-week program. "We pay close attention as they come in to the program each day, and [we] will pick up on cues when someone says they aren't able to sleep or they're not doing some of the things they used to enjoy," Paprocki said. "We can speak further with them to determine if these are short-lived issues or if they persist over time."
Cardiac rehab patients also attend educational sessions that described some of the possible sequelae from cardiac events, including depression.
"Some people listen quietly throughout the discussion, then come to us afterward and say, 'That's describing my life,'" Paprocki said. "Now we have a place at Springwood where they can receive group support and perhaps some antidepressants."
Screening Is Vital
Springwood's program has a lot of heart and soul in it. "Some of our clinicians and physicians had family members who developed depression after a cardiac incident, and professional organizations such as the American Heart Association strongly recommend regularly screening heart patients for depression," Osburn said. "Very often, cardiac events precipitate the first depression of a person's life, and our organization wanted to provide appropriate care to help them move forward and enjoy a better quality of life."
The program addresses symptoms of depression in cardiac patients, such as social withdrawal, fear of death or another cardiac event, hopelessness and recurrent thoughts about death or suicide. Program participants meet for 3 hours a day so they can balance their treatment requirements with work, education and home life schedules.
"Today, we're seeing people as young as 50 or 60 with no previous history of depression, and the common denominator is that major cardiac event," Osburn said.
Each person in the program is assigned to a case manager with a master's degree in counseling or social work. "Prior to admission to the outpatient program, we do a complete assessment," Osburn said. "We ask how they're doing with activities of daily living, because it's common to see a decline in those after a cardiac event. We look at their symptomatology and decide whether they meet criteria for the outpatient program."
Clinicians at Springwood share a message of hope with potential patients.
"They hear from us that appropriate diagnosis and treatment will enhance their medical status, improve their quality of life, decrease future disability and improve compliance with medical treatment," Osburn said. "We can help them deal with anger, fear of having another cardiac incident, dying from a cardiac incident and many other issues. Many individuals are afraid of returning to work, expecting their colleagues will see them as a weak link. And there's the issue of resuming sexual relations with a partner."
Osburn described the synergy between traditional cardiac rehab and Springwood's outpatient program for depression.
"While cardiac rehab programs do cover depression and other psychosocial issues, this focus is often the last item on the agenda toward the end of the program," she said. "Our intensive cardiac outpatient program is designed to focus on just those issues and give them coping skills to deal with the outcomes of the cardiac incident."
Paprocki agreed, noting, "That's the beauty of an outpatient cardiac rehab program, with all of us interacting with the participants each day to detect early onset of any issues. I had a gentleman in here the other day for an assessment; during the interview process, I could hear he was having trouble getting up each day and taking care of himself. I followed him closely through the cardiac rehab process, and he did come out of it. He was later able to tell me, 'Exercise made a difference.'"
On the other hand, there are participants who have significant and continuing depression that requires more intensive attention.
"If we don't catch those individuals early on, they will struggle and most likely fail to change their diet, attend cardiac rehab and maintain their home exercise program," Paprocki said. "The chances are, if a person is depressed, that individual will be less than successful in making those lifestyle changes that reduce the risk of another cardiac event."
Patients typically attend the Springwood program 3 hours a day, 3 days a week, for 4 weeks.
"Each day when they come into the center, they fill out goal sheets," Osburn said. "We ask them to rate their mood, sadness and anger on a 1-10 scale. Those ratings really help use identify the symptomatology to focus on that particular day in group sessions."
Each person has an individualized treatment plan and takes advantage of breakout groups focused on relevant issues.
"We may have one focused on anger management, another on tearfulness and a third on relationship stressors," Osburn said. "We can also do pullout therapy sessions when that's appropriate."
Group membership is dynamic as new people come in and others graduate from the program. .
"Someone might say, 'I'm so scared of what's happened and what might occur next,' and the rest of the group will reach out to help him," Osburn said. "Experienced members can give new members real-life experiences and talk about how the program has helped them make positive lifestyle changes and improve their lives. The new people can see how those changes have led to brighter affect and a sense of well-being, which gives them hope for their own future."
When it's time for discharge, clinicians and patients evaluate readiness. "Someone may come in with passive suicidal thoughts, anger, sadness or fear; over the weeks, you can see changes in the individual and determine they're ready for discharge," Osburn said. "Often, the participants themselves tell us, 'I feel so much better' or 'I really feel I'm ready to move on.'"
Sandy Keefe is a frequent contributor to ADVANCE.