Integrating Psychological Approaches Into the...

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Integrating Psychological Approaches

Into the Behavioral Management of

Modifiable Risk Factors

Alan Rozanski, M.D.January 30, 2013

• No disclosures

1. Define the rationale for integrating psychological approaches

2. Insights from Behavioral Cardiology

3. Illustrate practical principles and interventions

4. Discuss feasibility issues

Goals

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• CVD mortality decreased by ~60%

• Decreased prevalence of myocardial infarction

• Decreased severity of infarction

• Decrease in stroke

• Decrease in frequency and severity of myocardial ischemia

Favorable trends

•Remains #1 killer•Reliance on Rx’s isincreasingly costly

•Adverse trends inprevention

CVD mortality by 60%PrevaIance of MISeverity of MIprevalance of stroke Ischemia

Favorable trends

Challenges

J Am Coll Cardiol 2012; 59: 2125-43

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PATIENT EMPOWERMENT

Collaborativegoal setting

More effective education

Collaborative Rx planning

Patient self-management

Patient-centered cardiovascular care

a

“A vital component of PCC is educating and motivating patients to become better

stewards of their health and more active participants in the management of their

diseases”.





Goals

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Psychosocial Risk Factors

1. Negative emotions2. Negative thought patterns3. Chronic stress4. Poor social support5. Poor sleep 6. Inadequate R&R

Ovarian dysfunction

EVOKED CENTRAL RESPONSES

ANS Dysfunction

Insulin resistance

Central obesity

Metabolic syndrome

Inflammation

Platelet activation

Endothelial dysfunction

bone density

CNS changes

Depression• �� HPA

• �� SNS

DEPRESSIONANXIETYSTRESS

LONELINESS

POOR DIETWEIGHT GAINSEDENTARY

SMOKING

DRIVE

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• Epidemiology

• Pathophysiological study

• Study of behavioral consequences

• Little translation into cardiac practice

The “big disconnect”

Potential for clinical translation

• Vast field of Medical Psychology • This field has identified and developed

applicable evidence-based interventions• Applied psychology is commonly used in

many non-medical fields

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Goals

• John, a 55 yo very busy executive • Intermediate FRS• Moderately overweight• Highly sedentary • Increasing job stress• CAC scan: score = 180

Case example

• John, a 55 yo very busy executive • Intermediate FRS• Moderately overweight• Highly sedentary • Increasing job stress• CAC scan: score = 180

How do we get John to start and maintain anexercise program?

Case example

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MOTIVATION EXECUTION MAINTENANCE

3 Components of goal attainment

Presentation of risk

�FRS Biomarkers Bayesian analysis Exercise ECG Stress echo Stress nuclear �CAC scanning Carotid imaging CT angiography

Presentation of risk

�FRS Biomarkers Bayesian analysis Exercise ECG Stress echo Stress nuclear �CAC scanning Carotid imaging CT angiography

Does the presentation of risk information motivate patients?

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DESIGN OF THE EISNER TRIAL

2,137 volunteers with RFs,but no clinical disease

No scan group(n=713)

Scan group(n=1,424)

2:1 randomization

One time risk factorconsultation

4 YEAR CLINIC VISIT

One time RF consultationincluding scan result

4 YEAR CLINIC VISIT

RESULTS OF THE EISNER TRIAL

Compared to the no-scan group, the scan group showed net favorable change in:

– Systolic BP (p=0.02)

– LDL (p=0.04)

– Framingham score (p=0.003)

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IMPACT ON

PHYSICIAN

IMPACTON

PATIENTS

RISK INFORMATION

RISKINFORMATION

BEHAVIORAL CHANGE

Enhancing Motivation

1. Motivational interviewing2. Self-efficacy3. Autonomy

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• Express empathy• Elicit discrepancy between desired goals and

actual behavior(s) • “Roll” with resistance • Support self-efficacy

Motivational interviewing(Miller and Rollnick)

“Personal goal setting is influenced by self-

appraisal of capabilities.

The stronger the perceived self-efficacy, the higher the goal challenges people set for themselves

and the firmer is their commitment to them”.

SELF-EFFICACY

1997

People set goals and initiate new behaviors in

accordance with what they BELIEVE they can

accomplish

SELF-EFFICACY

11

20

15

10

5

Min

ute

s/ D

ay

30

25

Low Intensity

ModerateIntensity

HighIntensity

Prescription according to self-efficacy

AHA/ ACSM

Guidelines

20

15

10

5

Min

ute

s/ D

ay

30

25

Low Intensity

ModerateIntensity

HighIntensity

Prescription according to self-efficacy

AHA/ ACSM

Guidelines

John

PROMOTION OF AUTONOMY

EXTERNALMOTIVATION

INTERNAL MOTIVATION

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PROMOTION OF AUTONOMY

EXTERNALMOTIVATION

INTERNAL MOTIVATION

• Stronger initiative• Relapse less likely

PauseProvide

information

• John, why would you like to exercise?


Not sufficient

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MOTIVATION IS NOT SUFFICIENT(Shearan et al, 2002)

• Meta-analysis of 10 meta-analytic studies• 422 studies, involving 82, 107 participants

Intentions accounted for Only 28% of the variation in

behavior


~70% of variation


To make inspiration stick, you must root it to action

~70% of variation

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IN THE DOCTOR’S OFFICE

• Establish risk for CAD• Counsel John on the importance of exercise • Motivate John to exercise • Prescribe an exercise program that is agreeable

Intertemporal discounting

In the “moment”….

There is a universal tendency toovervalue present goals

and undervalue future goals

TEMPORAL DISCOUNTING

NEXTDAY @ WORK

IN THE DOCTOR’S OFFICE

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FuturePresent

Overcoming temporal discounting

• Make risk present-centered

• Make highly specific action plans

• Promote self-monitoring

• Automaticize the behavior

Future Present

FUTURE

RISK

PRESENT

EVIDENCE

THEORETICAL CONCRETE

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SPECIFICITY OF PLANS

MOTIVATION

GOAL

PLAN

SPECIFIC ACTION

BE HEALTHY

START EXERCISING REGULARLY

DAILY WALKS

WALK FOR 15 MINUTES AT LUNCH BREAKS

Telephone: 221-3399 State Reg. No

Name ______________________ Age____Address___________________ Date_____

Walk for 15 minutes @ 12:30 PM on weekdays

Dispense As Written

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• Promote self-awareness

• Platform for feedback

Future Present

Monitor baseline steps for one

week

Increase by X steps/wk

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avata et al, JAMA 2007; 298: 2296-2304)

• 26 studies (8 randomized, 18 observational)

• Mean step increase:– 2,491 in the RCTs

– 2,183 in the observational studies

• Decreased body mass index

• Decline in systolic blood pressure

(Bravata et al, JAMA 2007; 298: 2296-2304)






NEWPRACTICE

• Mindful & uncomfortable

HABIT

• Automatic

vs

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WORKLUNCH

BREAK

Too much to doToo tiredToo stressedNot in the mood

PRACTICE HABIT

Implementation Intentions(developed by Dr. Peter Gollwitzer)

• Identify an EXTERNALstimulus (X) to cue behavior

• “X” can be a place, a situation, or a time

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Implementation Intentions(developed by Dr. Peter Gollwitzer)

• Identify an EXTERNALstimulus (X) to cue behavior

• “X” can be a place, a situation, or a time

• Use the following formulation:

When it is “X”, I will do “Y”

“WHEN I HAVE MY LUNCH BREAK, I WILL TAKE A 15 MINUTE WALK”

John’s Implementation Intentions

X= Lunch breakY= Walking

Mental contrasting & Implementation Intentions(Stadler et al, AM J Prev Med 2009, 36:29)

Baseline

3840

56

103

49

One week 16 weeks

12096

ExerciseInformation MCII group

MIN

OF

EX

ER

CIS

E/ w

eek

256 women30-50 years

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Impact of Implementation Intentions(Gollwitzer & Sheeran, Advances in EP Social Psych, 2006)

Meta-analysisN=94 studies

8,461 participants

Implementation intentions have a medium to large

impact on goal achievement


Maintaining health behaviors

• Feedback

• Social support

• Contingency plans

• Stress management

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• Facilitates objective assessment & adjustments

• Provides emotional support

• Motivational

FEEDBACK

Feedback

• Arrange for on-going feedback

• Creative opportunities– Web-based support/ follow-up

– Smart phone technologies

– Office staff

Predictors of Patient Adherence(Dimatteo MR, Health Psychology 2004; 23:207)

Social network-support

Practical social support

Emotional support

Unidimensional social support

Family cohesiveness

Married

Living with someone

No. of studies

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11

27

14

51

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Odds ratio

3.60 [2.55, 5.19]

1.83 [1.27, 2.66]

2.35 [1.76, 3.03]

3.03 [1.99, 4.52]

1.27 [1.12, 1.43]

1.38 [1.04, 1.83]

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Social support

• Know your local hospital and community support resources

• Patient support groups

Contingency plans

StoppingStaying on the playing

fieldvs

StressTime pressureChanging prioritiesUnexpected eventsIllness

Contingency plans

Base plan• Walk every day

for 15 minutes

Contingencyplan

• Walk for 15 minutes/ weekends

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• Coping issues

• Emotional problems

• R&R

• Sleep hygiene

• Exercise

Screen

For

Stress

1. Define why we need to integrate psychological approaches

2. Overview of Behavioral Cardiology

3. Illustrate psychological principles and interventions

4. Discuss feasibility

Goals

Feasibility

• Evidence-based

• Practical to render

• Does not require special psychological expertise

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Time Allocation in Primary Care Offices( Tai-Seale et al, HSR 2007; 42: 1871)

n= 392 videotapesn= 392 videotapes

Median length of visits

Median # of topics

Time on chief complaint

Time on other topics

15.7 minutes

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~ 5 minutes

~ 1 minute

Physicians

Office Staff

Behavioralspecialists or

programs

Health care delivery

Alan Rozanski, M.D.

[email protected]

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