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6. Possible behavioural risk factors

These include exercise, coffee and alcohol consumption. The risk factors for CHD can be understood and predicted by examining an individual's health beliefs. Psychology, therefore, has a role to play in CHD in understanding and possibly changing these behavioural risk factors which can be resolved by using cognitive behavioural therapy (CBT).

Psychology and rehabilitation of CHD sufferers

The therapy is focused on the personal meaning of CHD for the patient, examining their coping strategies and emphasizing on their current problems, defined jointly by the therapist and the patients. Psychiatry also plays a role in the rehabilitation of individuals who have suffered a heart attack. Rehabilitation programs have been developed to encourage CHD sufferers to modify their risk factors such as exercise, type A behaviour, smoking and diet. It's most important aspect is cognitive behavioural therapy (CBT) along with medications like prothiaden which has both anti- anxiety and anti-depressant properties.

Cognitive behavioural therapy (CBT)

CBT uses the following techniques

• Identifying the patient's strengths and using these to develop their self-esteem overcome feelings of helplessness and promote their fighting spirit.
• Teaching patients to identify any automatic thoughts underlying their anxiety and depression and developing means to challenge these thoughts.
• Teaching patients to carry out activities, which give them a sense of pleasure and achievement in order to promote a sense of control.
• Encouraging expression of emotions and open communication.
• Teaching relaxation to control anxiety e.g. yoga, meditation, biofeedback etc.

Modifying exercise

Most rehabilitation programmes emphasize the restoration of physical functioning through exercise based upon the assumption that physical recovery will in turn promote psychological and social recovery. Meta-analyses of these exercise-based programmes have suggested that they may have favourable effects on cardiovascular mortality (e.g. Oldridge et al. 1998). However, whether exercise-based programmers influence risk factors other than exercise (e.g. smoking, diet and type a behaviour) is questionable.

Modifying type A behaviour

The Recurrent Coronary Prevention Project was developed by Friedman et al. (1986) in an attempt to modify type A behaviour. The study involved 1000 subjects and involved a 5-years intervention. The subjects had all suffered a heart attack and were allocated to one of three groups: cardiology counselling, type A behaviour modification, or no treatment. The type A behaviour modification group was involved in discussions that addressed their beliefs and the value of type A behaviour, methods for reducing work demands, relaxation and ways to change their cognitive framework. At a 5-year-follow-up, the results showed that the type A modification group showed a reduced recurrence of heart attacks, suggesting that not only can type A behaviour be modified, but that when it is modified there may be a reduction in the number of reinfarctions.

Modifying general lifestyle factors

Rehabilitation programmes have been developed which also focuses on modifying other risk factors such as smoking and diet. Van Elderen et al, (1994) developed a health education and counselling programme for patients with cardiovascular disease after hospitalization with weekly follow-ups.

The results showed that after 2 months the patients who had received health education and counselling reported health education and counselling reported a greater increase in physical activity and a greater decrease in unhealthy eating habits and showed a decrease in their smoking behaviour. At 12 months, the subjects who had participated in the health education and counselling programs maintained their improvement in their eating behaviour.

Conclusion

Coronary heart disease is a common cause of death in both the western and eastern world. The role of psychiatry in this illness is in terms of identifying and changing risk factors (e.g. smoking, diet, exercise and type A behaviour) in order to prevent CHD and developing programs to modify them in individuals who already have the disease. Also, treatment of anxiety, depression, panic disorder and specific phobias associated with coronary heart disease should be taken into account. Antidepressants like Prothiaden along with counselling, cognitive behavioural therapy and relaxation training like biofeedback, yoga, transcedental meditation and self-hypnosis should be considered.

Friends and family, sympathetic at first, often tire of the burden of driving the patients to appointments, to surgeries, and of hearing how much pain they have. Their love does not necessarily change (though it can) but they also feel a unique level of frustration.

Spirits sink gradually and almost immeasurably at first, then more and more, almost like a spiral-like water draining out of a sink with a clogged pipe slowly but inevitably, depression joins the pain.

And yet the question is begged: which came first, the pain or the depression?