Psychotherapy

Psychotherapy

Volume 33/Winter 1996/Number 4

REDUCING RISK FOR CARDIOVASCULAR DISEASE JOHN P. FOREYT WALKER S. CARLOS POSTON II Behavioral Medicine Research Center Baylor College of Medicine, Houston, Texas The focus of this review article is to examine the importance of psychological and socialfactors in the development and maintenance of cardiovascular diseases, primarily coronary heart and artery disease, and to provide an overview of the effectiveness of psychosocial risk reduction interventions. First we summarize the prevalence and economic burden of cardiovascular disease, as well as the role of psychosocial factors in disease development and progression. We then examine the primary modifiable risk factors and evaluate the role of psychotherapists in the treatment of heart disease. Finally, we assess the effectiveness of risk factor modification and rehabilitation interventions, describe the potential costs and benefits of these programs, and discuss the role of primary prevention programs. Cardiovascular diseases (CVD) comprise a number of disorders affecting the heart and circulatory system (Mile & Zipes, 1990). CVDs include coronary heart disease (CHD) and it's related complications, for example, angina, myocardial infarction (MI), and congestive heart failure, hypertension (HTN), and cerebrovascular disease. The common pathological condition un-

Thisresearchwas supported by National Institute of Diabetes and Digestive and Kidney Diseases Grant DK43109 and a Minority Scientist Development Award from the American Heart Association and it's Puerto Rican Affiliate. Correspondence regarding this article should be addressed to John P. Foreyt, 6S3S Fannin, MS F700, Houston, TX 77030.

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deriving these diseases is coronary artery disease (CAD), or coronary atherosclerosis, which is caused by fatty deposits lining arterial walls, leading to the narrowing of medium and large arteries (Smith & Leon, 1992). The most common forms of CVD, and the primary focus of this article, are those that affect the heart, including CHD and HTN. According to recent estimates, these two conditions together are the most prevalent chronic diseases in the United States, affecting a total of 192 individuals per 1000, or approximately 19 percent of the U.S. population (Benson & Marano, 1994). CHD is the leading cause of work-related disability among men over 50 and as many as 15% of heart disease patients are functionally disabled and do not return to work (Cooper, 1995; Oldridge, 1991). CVDs are the leading causes of death in the U.S., accounting for 44% of all mortality (Luepker, 1994). Of that, CHD and it's sequelae (e.g., angina, myocardial infarction, and heart failure) account for fully 79% of all cardiovascularrelated mortality (Luepker, 1994). CVDs result in enormous economic/health care expenditures. CHD and HTN are the most common reasons for adult physician visits and they were responsible for over 6 million hospitalizations in 1991 (Luepker, 1994). The direct costs associated with treatment of CHD and HTN (i.e., personal health care, hospital care, physician's services, nursing home services, other professional services, and drugs) were estimated to exceed 51.4 billion dollars (Wolf & Colditz, 1996). The total financial burden of CVDs in the U.S. was more than 108 billion dollars (Luepker, 1994). There are several established risk factors for the development and progression of CVD, most notably HTN, dietary factors (e.g., saturated fat and cholesterol levels), obesity, non-insulindependent diabetes mellitus (NIDDM) and insulin resistance, smoking and alcohol use, physical activity level, psychosocial factors (e.g., adherence

Reducing Risk behavior, stress, negative affect, social isolation/ support, occupational load, and Type A behavior pattern), and genetic vulnerabilities. With the exception of genetic factors, volitional behavior plays a substantial role in all of the above risk factors, which suggests that they are potentially modifiable. In fact, research has established that psychological, social, and biological factors are uniquely intertwined in the etiology and progression of CVD. Not only do psychological and social factors influence the development and course of the disease, they are also influenced by the disease and treatment regimens (Smith & Leon, 1992). It is not surprising, therefore, that behavior change strategies can play an important role in the modification of risk factors and the prevention and treatment of heart disease. The purpose of this article is to review briefly the importance of psychological and social factors in each of the modifiable risk factors, provide an overview of the effectiveness of CVD risk factor modification and rehabilitation programs, and discuss potential costs and benefits of these programs. CVD Modifiable Risk Factors Behavior plays a key role in all of the CVD modifiable risk factors (Smith & Leon, 1992). While some of these risk factors are not necessarily the direct result of behavior and lifestyle choices, or social and environmental conditions, they can be significantly influenced, both negatively and positively, by behavior change. It is therefore important to understand the role each of the factors play in CVD etiology and progression, as well as the role of behavior in each of the risk factors. Dietary Factors Data from numerous epidemiological studies suggest that risk for CHD is associated with higher lipid levels, most notably low-density lipoprotein (LDL) cholesterol, and lower levels of high density lipoprotein (HDL) cholesterol (Gaziano, Herbert, & Kennekens, 19%; Wynder, 1995). Many of these same studies have found a strong relationship between blood cholesterol levels and the consumption of animal fats or diets high in saturated fat and cholesterol (Barnard, Nicholson, & Howard, 1995; Keys, 1980; Littman, 1993a; Smith & Leon, 1992). In addition, other studies have documented reduced coronary risk in individuals who consume diets high in

fiber from cereals, vegetables, and fruit. For example, in a recent prospective cohort study, the multivariate relative risk of MI, after controlling for age, smoking, physical activity, dietary fat, total caloric intake, and alcohol use, was .81 for a 10 gram increase in dietary fiber above the fiber consumption of the comparison group (Rimm, Ascherio, Giovannucci, Epiegelman, Stampfer, & Willett, 1996). These data suggest that even after controlling for relevant factors, eating 10 grams more of fiber a day can result in a 19% reduction in the risk of a heart attack. While the lipid and fat hypothesis is not without critics (Stehbens, 1993), the preponderance of available data suggest that behavior and public health interventions aimed at reducing dietary fat and cholesterol and increasing fiber are warranted (DeBakey, Gotto, Scott, & Foreyt, 1996). Since psychological and social factors play important roles in dietary knowledge and selection (Logue, 1991), it is no surprise that dietary change is an important area in risk reduction and treatment of patients with CVD. Hypertension Hypertension (HTN), or high blood pressure, consists of elevations in systolic and diastolic blood pressure, usually defined as systolic readings exceeding 140 mmHg and/or diastolic readings exceeding 90 mmHg (Frolich, 1994; Miles & Zipes, 1990). Increased pressure can precipitate and accelerate damage to the lining of coronary arteries by exerting added force on the arterial wall (Miles & Zipes, 1990; Smith & Leon, 1992), thereby promoting cholesterol deposition at the site of arterial wall damage. These cholesterol deposits, or plaques, eventually build up and result in reduced arterial lumen circumference and blood flow to the heart (ischemia) which can lead to a heart attack. HTN, therefore, appears to contribute to the etiology and the progression of CAD, which is the precursor to heart disease. While HTN is not solely the result of behavior, it is strongly influenced by many behavioral factors, including obesity, NIDDM, physical inactivity, smoking, excessive alcohol use, and diet (Frohlich, 1994). Obesity and Non-Insulin-Dependent Diabetes Mellitus Both excessive body weight and NIDDM have been established as risk factors for heart disease. In general, the risk of CVD and MI increase for

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J. P. Foreyt & W. S. Carlos Poston II each level of body mass index (BMI), which is weight in kilograms divided by height in meters squared (Pi-Sunyer, 1993a; Webber, Wattigney, Srinivasan, & Berenson, 1995). For example, in women with no preexisting illnesses, there was a 106% increase in risk for CVD-related death among women with a BMI greater than 39 when compared to women with BMI's in the 27 to 30 range (Williamson, Pamuk, Thun, Flanders, Byers, & Heath, 1995). In addition, intentional weight losses of more than 20 pounds in the previous year were associated with a 25% reduction in cardiovascular-related mortality. NIDDM, which is strongly associated with obesity, is a potent risk factor of CVD and it often accelerates the development of HTN, heart disease, MI, and stroke (Smith & Leon, 1992; Sowers & Epstein, 1995; Wilson, 1994). It has been suggested that obesity, NIDDM, insulin resistance, dyslipidemia, and other precursors to CVD are all part of a broader syndrome which share common etiological underpinnings, including genetic vulnerabilities and adverse pre-and post-natal environmental events, such as poor nutrition and fetal exposure to problematic metabolic conditions associated with maternal adiposity (Reaven, 1994; Stern, 1995). Behavior change programs aimed at reducing obesity and NIDDM can have an impact on CVD. For example, small to moderate weight losses (5%-10% of initial weight) can substantially and positively impact HTN, blood lipids, and insulin resistance (Pi-Sunyer, 1993ft). While the longterm performance of weight loss programs has been less than optimal (Perri & Fuller, 1995), current data suggest that multimodal and continuous treatments can produce outcomes comparable to other chronic disorders (Kirschenbaum & Fitzgibbon, 1995). It should be apparent that there is ample work for therapists since many of the determinants of obesity and NIDDM involve modifiable behaviors such as physical activity, managing emotions, and eating behavior. Smoking and Alcohol Use Cigarette smoking ranks as one of the most important independent risk factors for CHD. The association between heart disease and smoking occurs in a dose-dependent manner and a significant amount of CHD mortality appears related to smoking (Pomerleau & Pomerleau, 1989; Smith & Leon, 1992; Wilson, 1994). As additional evidence, the excess risk of CHD associated

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with smoking is reduced by about half after 1 year of smoking abstinence and CHD patients who quit smoking reduce their risk for recurrence of MI or death by as much as 50% (Becker, 1994; USDHHS, 1990). Clearly, smoking cessation programs targeted at individuals with heart disease and public health efforts aimed at reducing the overall prevalence of smoking are a necessary component of any cardiovascular disease risk reduction effort. Since smoking is itself a complex, biopsychosocial phenomenon that is strongly influenced by psychological and social factors there is ample room for behavioral intervention. While it is true that smoking cessation outcomes (measured as 1-year abstinence from smoking) have generally not been as high as desired (Lichenstein & Glasgow, 1992; Shiftman, 1993), cessation programs targeted at cardiac patients have yielded more promising results, with 1-year abstinence ranging from 50% to 70% using behavioral interventions alone and combined behavioral and pharmacological programs (Gritz, Kristeller, & Burns, 1993). The picture for alcohol is somewhat different. Moderate alcohol consumption appears to raise levels of high density lipoproteins (HDL), which is cardioprotective. It is important to note that the potential cardiovascular benefits of moderate alcohol use do not extend to individuals who consume excessive amounts (Kuller, 1994). For example, large doses of alcohol can be cardiotoxic and result in cardiomyopathy. In addition, alcohol can raise blood pressure, so decreased or discontinued use of alcohol may be important for hypertensive or cerebrovascular patients (Kuller, 1994). Physical Activity Sedentary lifestyle, characterized by low levels of physical activity, is an important and modifiable risk factor for CHD (Blair, Horton, Leon, Lee, Drinkwater, Dishman, Mackey, & Kienholz, 1996;Haskell, 1994). Sedentary individuals are twice as likely to die from heart disease when compared to individuals who engage in regular and vigorous activity and 16% of CHD-related mortality in the population can be attributed to inactivity (Powell & Blair, 1994). This is a particularly problematic issue because a large portion of the adult U.S. population is sedentary. Less than 10% of women or men in the U.S. engage in regular and vigorous activity, and nearly 60% report a sedentary lifestyle (CDC, 1993; Pate,

Reducing Risk Pratt, Blair, Haskell, Macera, Bouchard, Buchner, Ettinger, Heath, King, Kriska, Leon, Marcus, Morris, Paffenbarger, Patrick, Pollock, Rippe, Sallis, & Wilmore, 1995; USDHHS, 1996). On the other hand, regular physical activity of moderate to vigorous intensity appears to be cardioprotective (Blair et al., 1996; Haskell, 1994; Pate et al., 1995). In general, most studies find that physically active people develop CHD at a lesser rate than do their sedentary counterparts, and, if they do develop heart disease, it is later in life and less severe (Haskell, 1994). In addition, regular, moderate intensity physical activity appears to convey some health benefits in the form of reducedriskfor CHD and death (Haskell, 1994; Pate et al., 1995). Regular exercise is also an important component of cardiac rehabilitation and appears to afford some reduction in risk for recurrence. Unfortunately, there are many psychosocial factors that negatively impact adherence to regular physical activity on the part of cardiac patients and the general public that need to be addressed by psychotherapists (Blair et al., 1996; Haskell, 1994). Psychosocial Factors Type A Behavior Pattern (TABP). A broad variety of psychological and social constructs have been associated with the development and progression of CHD. One of the most heavily researched and debated is the Type A Behavior Pattern (TABP) or Type A personality (Smith & Leon, 1992; Thoresen & Powell, 1992). TABP is a complex syndrome characterized by the following behavioral traits or tendencies: time pressured; competitive; impatient; aggressive; hostile; and cynical (Levine, 1994; Smith & Leon, 1992; Thoresen & Powell, 1992). This behavior pattern is thought to contribute to the development of heart disease because the individual tends to respond to the environment in a manner that elicits recurrent and heightened levels of sympathetic nervous system arousal. This persistent overarousal may precipitate the development of CHD by contributing to arterial wall damage and the deposition of cholesterol plaque (Smith & Leon, 1992). This is supported by studies showing that individuals who exhibit TABP tend to have greater heartrateand blood pressure reactivity in response to stressful situations. In addition, TABP individuals may further contribute to the problem by creating stress in their lives due to

their tendency to view challenges as threats and respond to events in a manner characterized by competitiveness and hostility, which further evokes and prolongs exaggerated nervous system arousal (Smith & Leon, 1992). While numerous retrospective and crosssectional studies supported the hypothesis that individuals with these traits were more prone to heart disease, the results of several prospective investigations were more equivocal (Levine, 1994; Thoresen & Powell, 1992). There are several potential theoretical and methodological reasons for the lack of consistency in TABP studies, including the use of different measures of TABP with varying degrees of reliability and validity, the failure to recognize the transactional nature of TABP, and the broadness of the construct (Foreyt, 1990). In spite of these limitations, the preponderance of the evidence from both prospective and retrospective investigations suggest that there is a modest, but significant relationship between TABP and CHD, at least for men (Goldstein & Niaura, 1992; Niaura & Goldstein, 1992; O'Connor, Manson, O'Connor, & Buring, 1995; Smith & Leon, 1992; Thoresen & Powell, 1992). Hostility and Cynicism. Components of TABP also have been linked independently to CHD, most notably the constructs of hostility and cynicism. Several prospective investigations have found an association between hostility and antagonistic interactions, as measured by hostility and cynicism scales, and CHD incidence, severity, and mortality (Goldstein & Niaura, 1992; Levine, 1994; Smith & Leon, 1992). Similar to the more general TABP, hostility and cynicism are thought to berelatedto the development of CHD through the more frequent and recurrent episodes of heightened physiological arousal in response to potentially stressful situations. Individuals with high hostility scores are more likely to exhibit elevated blood pressure in response to stressful interaction, increased plasma lipid levels and nervous system reactivity in stressful work settings, increased cortisol levels during daily activities, and more frequent and severe interpersonal conflicts (Smith & Leon, 1992). Emotional Distress, Depression, and Type-D Personality. Emotional distress and depression also have been linked with development and progression of CHD and with outcome and prognosis variables such as reduction in long-term survival in heart disease patients and rehospitalization rates, although the role of anxiety is unclear

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J. P. Foreyt & W. S. Carlos Poston II (Frasure-Smith, Lesperance, & Talajic, 1993, 199S; Littman, 19936; Niaura & Goldstein, 1992). For example, there is evidence that patients experiencing major depressive disorders are at greater risk for cardiovascular morbidity and mortality (Frasure-Smith, L6sperance, &Talajic, 1995; Goldstein & Niaura, 1992). Distressed cardiac patients are likely to use more medication, and experience rehospitalization, recurrent events, and death than non-distressed patients (Allison, Williams, Miller, Patten, Bailey, Squires, & Gau, 1995). Distressed patients are over four times more likely to experience early cardiac-related rehospitalization than non-distressed patients, even after adjusting for disease severity and other biomedical risk factors. In addition, cardiac patients who tend to experience high levels of negative emotions and suppress their emotional distress (referred to as Type-D personality) have been found to have a greater risk for mortality when compared to those patients without type-D personality styles. For example, the multivariate risk for death at 6-10 years from baseline for type-D cardiac patients was 4.1 times greater than patients without type-D personality styles, even after controlling for other biomedical predictors (Denollet, Sys, Stroobant, Rombouts, Gillebert, & Brutsaert, 1996). A limitation of this work is that it is difficult to determine whether or not distress is a stable trait or a reaction to suffering from a chronic medical disorder. It is therefore not possible to determine if type-D personality or psychological distress is a significant factor in the development of CHD. Nevertheless, these studies suggest that depression, distress, or negative emotions are useful predictors of negative outcomes for cardiac patients and that they should be assessed and treated as part of standard cardiac rehabilitation when indicated (Allison et al., 1995; Denollet et al., 1996; Frasure-Smith, Lesperance, & Talajic, 1995; Goldstein* Niaura, 1992;Lesp6rance & Frasure-Smith, 1996; Niaura & Goldstein, 1992). Stress. Stress has been linked to the development of CHD, although it is a very broad and sometimes poorly defined construct. More specific aspects of stress, such as occupational stress (e.g., jobs with high workloads, few growth possibilities, low control or involvement in decisions, and low social support), high degrees of life stress, and social isolation have been linked with increased incidence of heart disease and

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CHD-related mortality (Levine, 1994; Niaura & Goldstein, 1992; Smith & Leon, 1992). High levels of social support have been found to mitigate e effects of these and other risk factors on several CHD endpoints while low levels appear to contribute to disease development (Niaura & Goldstein, 1992). hi addition, some of these same factors can have an impact on the prognosis and outcome of disease sufferers. For example, low levels of perceived social support and frequent life stress are predictors of disease and event recurrence in post-MI patients (Bucher, 1994; Friedmann, & Thomas, 1995; Ruberman, Weinblatt, Goldberg, & Chandhary, 1984). In a prospective evaluation, the risk of a major cardiac recurrence in post-MI patients living alone was 150% more than for individuals not living alone (Case, Moss, Case, McDermot, & Eberly, 1992). Adherence. Variations in adherence to rehabilitative and preventive measures also are important risk factors in the development of and recovery from heart disease (Levine, 1994). For example, poor adherence to dietary recommendations and medications in the treatment of HTN, obesity, or NIDDM, can play an important role in the development and progression of heart disease as well as have a significant and negative impact on long-term recovery and survival (Burke & Dunbar-Jacobs, 1995; Foreyt & Poston, 19%; Levine, 1994). Since there are many influences that play a role in adherence behavior, including patient characteristics, the relationship and communication between patients and their providers, disease course and severity, the demands of the treatment regimen, and any number of social and environmental issues (e.g., financial factors, social support, and accessibility of the medical treatment center), there is ample room for therapists to develop interventions aimed at maximizing adherence (Burke & Dunbar-Jacobs, 1995; Foreyt & Poston, 1996). CVD Risk Factor Modification and Rehabilitation Program Effectiveness There have been two primary approaches regarding psychosocial interventions. The first approach, which can be conceptualized as primary and secondary prevention efforts, focuses on universal and targeted risk factor reduction. Due to economic and practical concerns, most research emphasizes the latter. The second approach, tertiary prevention or rehabilitation programs, tends to focus on individuals who have already experi-

Reducing Risk enced a cardiac event (e.g., MI, angina, or atherosclerosis). Risk factor reduction programs generally have been developed for individuals assumed to be a higher risk for CHD, that is, individuals with elevated lipids or diets high in fat and cholesterol, smokers, individuals who are obese, have HTN or NIDDM, exhibit TABP or other patterns of risk factor behavior, or any combination of the above. Mostriskreduction interventions are multifactorial, since many individuals exhibit two or more of the risk factors. Comprehensive programs may include cognitive-behavioral therapy for stress reduction and emotional problems, vocational counseling and placement, family therapy, nutritional counseling, smoking cessation, exercise training and physical therapy, and adherence counseling (Blumenthal & Wei, 1993; Smith & Leon, 1992). Rehabilitation programs are also multifactorial and the line between risk factor reduction and rehabilitation is often a thin one (the main difference being the target population and the intensity level of the intervention). Psychosocially-oriented risk reduction and rehabilitation programs take many forms and emphasize different interventions, depending on the needs of the target population. For example, some programs provide services through individual counseling while others utilize group and family psychotherapy (Linden, Stossel, & Maurice, 1996). Interventions also vary in terms of the problems that they focus on or the outcomes of interest. For example, programs emphasize the importance of improving quality of life in different ways. Some programs focus on managing anger, stress, anxiety, and depression and improving marital communication or interpersonal relationships, while others focus almost entirely on making and maintaining lifestyle changes, including reducing dietary fat and calories, weight loss, smoking cessation, and increasing regular exercise (Blumentahl & Wei, 1993; Smith & Leon, 1992). In addition, some programs target specific problems, such as self-regulation training (e.g., relaxation training with or without biofeedback, autogenic therapy, or meditation) for high blood pressure and stress, cognitivebehavioral therapy for stress, anxiety, or depression, couples therapy for marital and sexual issues, or behavior therapy for smoking cessation (Becker, 1994; Bennett, & Carroll, 1994; Blumenthal & Wei, 1993; Gritz et al., 1993; Johnston, Gold, Kentish, Smith, Vallance,

Shah, Leach, & Robinson, 1993; McCrady, 1994; Smith & Leon, 1992; Zamarra, Schneider, Besseghini, Robinson, & Salerno, 1996). None of these approaches necessarily excludes others and the selection of psychosociallyoriented interventions should be made based on the needs of the target population, the ability and skills of the treatment team, and the practical and economic feasibility of the different treatment components for specific settings and populations. In general, the outcomes for psychosocial treatment of individuals with CVD risk and coronary patients have been fairly favorable. For example, a recent meta-analysis of psychosocial interventions for cardiac patients found that those receiving psychosocial interventions in addition to usual care demonstrated greater reductions in systolic blood pressure, heart rate, and cholesterol levels than patients receiving usual care only (Linden et al., 1996). When only randomized, controlled trials were considered, treated patients experienced considerable reductions in morbidity and showed improvements in long-term survival. Overall, psychosocially-treated patients experienced a 46% reduction in nonfatal cardiac events and a 41% reduction in mortality with 2 years or less follow-up and a 39% reduction in nonfatal cardiac events with more than 2 years of followup. When nonrandomized, controlled trials were included, reductions in morbidity and mortality were even more substantial, suggesting that psychosocial treatments have an important impact on physical and mental functioning, quality of life, and long-term survival (Linden et al., 19%). Other studies and meta-analyses have found similar results for post-MI and congestive heart failure rehabilitation programs (Bennett & Carroll, 1994; Kostis, Rosen, Cosgrove, Shindler, & Wilson, 1994; Mitsibounas, Tsouna-Hadjis, Rotas, & Sideris, 1992; Oldridge, Guyatt, Fischer, & Rimm, 1988; Trzcieniecka-Green & Steptoe, 1994). In addition, psychosocial treatments can produce reductions in risk comparable to medical treatments. For example, when only randomized controlled trials of behavioral therapies were considered, the cumulative weighted percent relative risk reduction (WPRRR) was about - 3 9 % for nonfatal Mi's and - 33% for cardiac deaths (Ketterer, 1993). This compares very favorably with traditional medical treatments such as beta-blockers for post-MI patients (nonfatal MI WPRRR =

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J. P. Foreyt & W. S. Carlos Poston II - 27%, cardiac death WPRRR = - 22%), cholesterol reduction (nonfatal MI WPRRR = - 1 7 % , cardiac death WPRRR = -10%), and treatment of HTN (nonfatal MI WPRRR = - 8 % , cardiac death WPRRR = -11%) (Ketterer, 1993). Some of the most researched risk factor reduction and rehabilitation interventions are multifactorial programs aimed at individuals who exhibit TABP (Levine, 1994; Thoresen & Powell, 1992). A meta-analysis of TABP interventions found that patients undergoing psychological treatments reduced their TABP scores on a standardized measure by half a standard deviation and that there was a corresponding 50% reduction in coronary events over a three year period (Nunes, Frank, & Kornfeld, 1987). These results are even more striking because modifications in other risk factors, such as smoking and serum cholesterol, were minimal. Finally, studies of other specifically focused interventions have yielded promising results. For example, when the focus is coronary artery disease regression, nonpharmacological trials, consisting of various combinations of smoking cessation, dietary change, exercise, and stress management, yield weighted percent disease regression indices that compare favorably with medication trials (Superko & Krauss, 1994). Targeted smoking cessation programs for cardiac patients also produce better participation and one year abstinence rates than usual care or programs for nonpatient populations (Kristeller, Merriam, Ockene, Ockene, & Goldberg, 1993; Ockene, Kristeller, Goldberg, Ockene, Merriam, Barrett, Pekow, Hosmer, & Gianelly, 1992; Taylor, Houston-Miller, Kollen, & DeBusk, 1990). Behaviorally-oriented adherence interventions also have demonstrated improvements in medication use, dietary change, and exercise and physical activity (Barnard, Akhtar, & Nicholson, 1995; Brownell & Cohen, 1995; Burke & DunbarJacobs, 1995; Foreyt & Poston, 1996; Levine, 1994). CVD Risk Reduction and Rehabilitation Cost Outcomes No discussion of psychosocial treatments would be complete without considering the costs involved in developing and implementing programs compared to the benefits received by patients and offsets to the health care system. Since health care resources are limited, it is important

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to evaluate programs and assess their costs against the benefits they provide and the potential offsets they may have in terms of reduced medical costs. When evaluated in terms of lost productivity due to CVD, cardiac rehabilitation programs can be beneficial. For example, in 1990, estimated costs for cardiac rehabilitation services were $120 million dollars, but this pales in comparison to the estimated $14.2 billion dollars incurred due to lost productivity (Oldridge, 1991). Cardiac rehabilitation programs also provide cost offsets in terms of reduction in rehospitalization costs. For example, per capita hospitalization charges were $739 lower for participants than nonparticipants, due mainly to less frequent rehospitalization and lower charges for each hospitalization (Ades, Huang, & Weaver, 1992). In addition, cardiac rehabilitation programs can be less expensive than many medical treatments, particularly for post-MI patients who are experiencing mild to moderate emotional distress. For example, the cost-utility/quality-adjusted life-year estimates for cardiac rehabilitation patients are lower than medical treatment for mild hypertension and the cost-effectiveness estimates are comparable to many medication treatments, indicating that rehabilitation programs are an efficient use of health care resources (Oldridge, Furlong, Feeny, Torrance, Guyatt, Crowe, & Jones, 1993). Given that psychologically distressed cardiac patients utilize more health care services and therefore cost more to treat, it makes sense to provide psychological intervention programs for them as a routine part of post-MI treatment. In fact, there is now increasing evidence that psychological services can provide cost-offsets for a number of medical problems (Friedman, Sobel, Meyers, Caudill, & Benson, 1995). For example, Medicare enrollees who used managed psychological treatment reduced medical costs by 9.5% to 21% over 18 months after treatment cessation while nonenrollees increased their annual medical costs (Pallak, Cummings, Dorken, & Henke, 1995). CVD Prevention While the focus of this article has been on reviewing the value, effectiveness, and potential cost-effectiveness of psychosocial interventions for CVD risk reduction and rehabilitation, it is also important to recognize the role of primary prevention. At the policy and environmental inter-

Reducing Risk vention level, greater emphasis should be placed on the role of lifestyle factors, such as poor diet and sedentary lifestyle, in the development and maintenance of heart disease (Genest & Conn, 1995). Since less than 10% of American men and women engage in regular and vigorous physical activity (CDC, 1993; Pate et al., 1995; USDHHS, 1996), decreasing sedentary lifestyle and increasing the physical activity of all Americans, particularly individuals who are at increased risk for heart disease, should be a national public health policy. This is very important since regular physical activity has been found to impart many cardiovascular benefits and to reduce risk for death from all causes (Bernadet, 1995; USDHHS, 1996; Whaley & Blair, 1995). For example, lower cardiovascular disease-related mortality rates have been found for individuals in higher fitness categories (Blair, et al., 1996; Blair, Kohl, Paffenbarger, Clark, Cooper, & Gibbons, 1989). More resources should be directed at developing prevention programs as early in life as possible, since many problematic lifestyle behaviors related to CVD, including poor eating habits, lack of physical activity, and smoking, often start or are primed in childhood (Cunnane, 1993; Epps, Manley, & Glynn, 1995). Preliminary data suggest that smoking cessation and exercise programs can be cost-effective as preventive interventions (Kupersmith, Holmes-Rovner, Hogan, Rovner, & Gardiner, 1995). It is imperative that future research address the effectiveness of these interventions, when to implement them, and their cost-effectiveness. Conclusions The preponderance of data suggest that CVD risk reduction and rehabilitation programs are effective and provide benefits that are well worth the costs. These programs produce improvements in physical and psychological functioning as well as hard endpoints, such as reduced recurrences and lower mortality. They also provide cost benefits and offsets in terms of reductions in medical costs and in lost productivity. Psychosocial therapy programs for cardiac patients are an important area for psychologists and psychotherapists interested in providing effective treatments to a patient population in serious need of services. But before providing such services, it is important that therapists receive adequate training and supervision in providing treatment to medical patients. For many

traditionally trained psychologists, the assessment and treatment methods may be unfamiliar. In addition, many therapists do not have adequate knowledge of general physiology, anatomy, or cardiac disease pathophysiology and course (Frank & Ross, 1995). It is both ethically and professionally important that psychologists who do not have a background in health and rehabilitation psychology receive adequate training through formal postdoctoral fellowships or continuing education and supervision. The Health Psychology division (Division 38) of the American Psychological Association (APA) developed guidelines for postdoctoral education and training for clinicians wanting to provide these services (Sheridan, Matarazzo, Toll, Perry, Weiss, & Belar, 1988). We recommend reviewing these guidelines as a first step to providing services to patients with CVD. References ADES, P. A., HUANG, D., & WEAVER, S.O. (1992). Cardiac

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