What's the link between mental health and heart disease?

A new CBT-like treatment for anxiety and depression called 'metacognitive therapy' has been shown to improve symptoms in heart disease patients. Doctors explain how mental health and heart disease interact, and how treating one can improve outcomes for the other

The psychological effects of heart disease

Harriet Dawson, 24, was 22 when she was diagnosed out of the blue with a hole in her heart. She had open heart surgery and, physically, felt much better. But the shock of the diagnosis hung around.

Debra Hallam, 49, also had a heart condition that required open heart surgery, as well as coping with a couple of long-term health issues.

Both of them took part in the PATHWAY study - Harriet via a solo online programme and Debi in a group - and both of them say it supported them as they recovered from their heart problems.

Harriet says she was worried that the sudden nature of her diagnosis would ramp up her anxiety around the possibility she had other undiagnosed problems. But, she says, learning to deal with anxiety was a massive help.

"You learn to deal with what has happened and how to put it to one side," Harriet says. "You do it in such a methodical way - for example, I had a designated 10 minutes to worry about my health and found that by the time I got to it, either I'd forgotten the worry or I don't have enough to worry about. The worry has not gone away, but the stress around it has."

Debra said she felt impressed by seeing how much of a difference metacognitive therapy made to her perspective, and to other participants' anxiety, and the lessons she learned were memorable.

"It's something that I carry with me all the time now and pass on to other people. It's a really good life skill," she says.

What is metacognitive therapy?

The background

Prof Adrian Wells trained as a psychologist and later trained to deliver cognitive behavioural therapy, a type of talking therapy. But he wondered whether there was a better way to help some of his patients.

He developed metacognitive therapy (MCT) in the 1990s and since then has been building the evidence basis for it. Most recently he published a study showing that it significantly improves anxiety and depression symptoms in heart disease patients.

The theory behind metacognitive therapy

Metacognition is the element of cognition that controls mental processes and thinking. It can work to inform you that information is stored in your brain, even though you can't quite grasp it - the so-called 'tip of the tongue' effect. People who have depression or anxiety often dwell on negative thoughts and adapt their lives and actions to avoid perceived threats or consequences - the so-called cognitive-attentional syndrome (CAS). It is these unhelpful negative cycles that metacognitive therapy seeks to address, by removing the CAS and helping people modify their metacognitive beliefs and reaction to negative thoughts.

Prof Wells, now a professor of clinical and experimental psychopathology at Manchester University, explains that metacognitive therapy means treating the part of us that monitors and controls thoughts, but unlike cognitive behavioural therpay, metacognitive therapy doesn't focus on content of what we think.

"For example, in a case of social anxiety disorder, the CBT therapist will question the validity of a negative thought, 'Where's the evidence that people think you're stupid?', while the metacognitive therapist aims to reduce the overall amount of thinking the patient engages in and asks: 'What's the point in analysing what others think? Let's explore how you can reduce the activity.'"

Putting metacognitive therapy into practice

Metacognitive therapy typically lasts six to 12 sessions and introduces techniques to help people to become more aware of their thinking patterns and to make changes.

The NIHR has now funded a pilot study on implementing metacognitive therapy on the NHS. Prof Kathryn Abel, NIHR clinical research network lead for mental health, said that PATHWAY's findings were 'incredibly encouraging' and present the first evidence that a psychological treatment may prevent development of common mental disorders in cardiovascular disease.

What's the link between heart disease and mental health?

You're more at risk of developing circulatory and heart diseases if you have a mental health condition, and the British Heart Foundation (the UK's leading charity for heart disease) advises its readers as much.

Likewise, the charity advises elsewhere, stress is an indirect risk factor for heart problems.

It seems like common sense to describe heart problems as a factor for developing mental health problems. Heart attacks and strokes are self-evidently stressful, and chronic health conditions (such as diabetes and bowel disease) often exacerbate a person's risk of developing or having a relapse of depression or anxiety.

Experts have also been keen to explore the bidirectional relationship between heart problems and mental health - that is, whether mental health problems can themselves increase our risk of developing heart problems.

Last year a paper studying half a million people warned that people who experience symptoms of depression are more likely to go on to develop heart disease or suffer a stroke than those who report good mental health. However it is worth noting that the increased risk in the study was modest and observed over a long period of time - which is to say, it didn't find that feeling depressed or having a depression diagnosis gave people heart disease or strokes. It might be that treating mental health problems reduces risk of heart problems but we just don't have the evidence for that yet.

In addition, it's possible that the link between mental health and heart disease is, at least in part, indirect: people with mental health problems may take less care of their physical health, and it may be this consequence of mental ill health that leaves them at greater risk of heart disease. We know the risk factors we can change that have a strong evidence basis: high cholesterol, smoking, physical inactivity and obesity. If you're worried about your heart health, start there - exercise is also well evidenced as a protective factor against common mental health problems.

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COVID-19, mental health and heart disease

Ruth McNiven, senior cardiac nurse at the British Heart Foundation, said: "Getting a diagnosis of cardiovascular disease is always hard for people and, even before the pandemic, many living with heart and circulatory disease were already experiencing significant psychosocial challenges, including treatment-related fears and anxiety, and uncertainty about the future.

"The pandemic has led to increased waiting times for procedures and treatments across the UK , which has had further impact on individuals’ emotional well-being.

"The PATHWAY study suggests that a behaviour change approach to managing anxiety is beneficial when delivered as part of cardiac rehab. While further study into management techniques should continue, in the short term we must ensure psychological support is available to people living with heart and circulatory conditions if they need it."

Life after cardiac rehab

Debra's treatment was four years ago now but she says she still uses some of the techniques she learned during the metacognitive therapy programme. "The main thing that I have taken away, and I still use every day, is that worry and anxiety are basically a waste of time and energy, and they don't change anything," she says.

Likewise, Harriet says she's still appreciative of the support the study gave her. She still has health worries but after cardiac rehabilitation she got an internship, and hopes to travel after the pandemic recedes.

"I could have definitely spiralled had I not got a grip of it and studied why I felt like that and how I could deal with it," she says. "It was really important to recognise what I'd been through and I learned a lot about myself as a person from both what happened, and from taking part in PATHWAY."

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