Week 10 Flashcards
How big a health issue is CVD in the uk
Heart and circulatory diseases kill 1 in 4 people in the UK
Rates and outcomes of CVD in those with mental illness
People with severe mental illness have:
-higher incidence of CVD: HR 1.78 (95% Cl 1.60-1.98, n=31 studies)
-high CVD related mortality : HR 1.85 (95% Cl 1.53-2.24)
Includes conditions such as major depressive disorder, schizophrenia, bipolar disorder
Public health outcomes framework relevant to CVD (examples)
Obesity in early pregnancy
Smoking in early pregnancy
Low birth weight of term babies
Prevalence of childhood overweight/obesity
Percentage of physical active children and young people
Proportion of the population meeting the recommended 5 a day
Percentage of individuals aged 40-74 who received an NHS health check
NICE public health guidance 25, 2010
Reduce population level consumption of salt
Reduce population level consumption of saturated fat
Eliminate the use of industrially produced trans fatty acids for human consumption
Prevent marketing which encourages unhealthy diet in children
Transparency about commercial interests
Product labelling
Assess impact of government policy on CVD
Making every contact count
Behaviour change based on brief interventions
Makes use of the millions of day to day interactions health service providers have with individuals
Targets behavioural risk factors
-tobacco use
-alcohol
-physical activity
QOF
Maintain registers of patients with CVD
Maintain register of patients with BMI>30
Anti coagulation in patients with CHA2DS2-VASCULAR score>2
Antiplatelet prescription in patients with CHD
Antiplatelet or anticoagulants in patients with ischaemic stroke/TIA
Control of BP in patients with CHD
NHS health checks
Individuals aged 40-74 without pre existing long term conditions
Designed to identify early signs of CVD, kidney disease, type 2 diabetes, and dementia
Questions on smoking, alcohol, and physical activity
BMI, BP, cholesterol
Cardiovascular risk assessment
Advice on improving lifestyle risk factors
Uptake is highest in older people and females
Uptake is lower in those living in most deprived areas
Just under half of those invited attended
General health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments
Nuffield bioethics ladder of intervention
Eliminate choice
Restrict choice
Guide choice by disincentives
Guide choice by incentives
Guide choice by changing default policy
Enable choice
Provide info
Do nothing
Other factors to consider
Individual autonomy versus welfare of the population (paternalism)
Free trade
Cost to economy
Public opinion
Political lobbying
Role of advocacy
Geoffrey rose
Sick individuals and sick populations
Individual (high risk strategy) versus population approach to disease prevention
A large no. Of people at small risk may give rise to more cases of disease than the small no. Who are at high risk
“High risk” strategy
Identify high risk individuals and provide appropriate health interventions to reduce future risk
Advantages: intervention appropriate to individual, subject motivation, physician motivation, cost-effective use of resources, benefit: risk ratio favourable
Disadvantages: difficulties and costs of screening, palliative and temporary, limited potential for individual/population, behaviourally inappropriate
Population approach
Control the determinants of disease
Lower mean level of risk factors
Shift the population distribution of exposure
Advantages: radical, large potential for population, behaviourally appropriate
Disadvantages: small benefit to individual (prevention paradox), poor motivation of subject, poor motivation of physician, benefit: risk ratio worrisome
Overview of topic of coping with chronic illness
Coping describes how we manage stressors, such as chronic illness
This allows us to achieve adaptation
-how we can adjust aspects of our thinking/emotions/behaviour so that we can live successfully with a chronic illness
Coping (folkman and Lazarus 1980)
Psychological mechanism for managing external stress, may be action oriented (doing something) and thought based
Chronic illness
Lasting 3 months or more, cannot be prevented by vaccine or cured by medication or self resolve. 80% of >65s have at least one chronic health condition
Stress (Hans 1993)
Stress is ‘whatever stresses people’
Some early models of coping
Canons flight or fight model:
-threat leads to increased arousal in order to escape
Selye’s general adaptation syndrome:
-“alarm” increases activity, “resistance” is attempt to cope, “exhaustion” when cant resist anymore
Problems with previous models
Did not address individual variability or psychological factors
Response was very automatic and physiological and so consistent- does not reflect clinical practice
Transactional model of stress (Lazarus)
Primary appraisal- “is this stressful”
-irrelevant
-benign and positive
-harmful and a threat
-harmful and a challenge
Secondary appraisal-“can i cope with this”
-evaluating internal coping strategies
Interaction with external world and how appraises it is key
Stressor- primary appraisal
“In the beginning i told them they must be dreaming… it’s a bad bad dream”
“People cannot stand this… feeling that you have to be positive”
“I was deeply sad and scared… i was scared to death on the way to the hospital”
Secondary appraisal
“I stood outside the breast centre and screamed, shouted and swore”
“Theres no denying that i panicked at the beginning. Then i seemed to be overtaken by an icy, practical calm, ok i thought deal with it”
Folkman (1986)
Problem focused:
-aimed at resolving the stressful situation or event
-taking control
-seeking information
-removing oneself
Emotion focused:
-disclaiming
-escape avoidance
-accepting responsibility or blame
-self control
-positive reappraisal
Problem focused coping
Take action to reduce demands of stressor
Or to increase resources so able to manage it
E.g revision plan, setting agenda, studying for extra qualifications to enable career change, counselling for failing relationship
Emotion focused coping
Attempts to manage emotion caused;eg:
-seeking emotional support
-denial
-venting anger
-distraction
-praying
-exercise
-alcohol/drugs
-humour
-DSH
-suicide
Does stress cause illness
Some personality traits more common in high stress jobs
Higher life stress- report more physical symptoms
Stressful jobs have higher rates CHD
Increased mortality
How does stress cause illness
Chronic stress causes prolonged interaction between physio/bio/psychological factors
-atherosclerosis well researched
-acute stress more likely to provoke MI
Stress also changes behaviour:
-increased smoking
-increased alcohol
-poor diet
-lack of exercise
-increased accidents
How people cope
Coping is context dependent and dynamic
Eg depends on if there is a practical solution
Times/reosurces/money available
Personality factors and past experience
Coping with pain
Appraising stress as a threat produces a negative emotional responses, and vulnerability
Appraising stress as a challenge is a positive response which focuses on growth and mastery (Lazarus and Folkman 1984)
Pain in patients often have negative and maladaptive appraisals about the situation and their own ability to control pain and thus tend to appraise their pain as a threat (Turk and Flor, 1999)
Rely more on emotion focused coping (smith and wallston 1992)
Active (problem focused) coping associated with better physical and psychological functioning
Passive coping (eg emotion-focused coping) associated with poor physical and psychological functioning (Jensen et al 1991)
Associations have also been reported between depression and emotion focused coping strategies in chronic pain (endler et al 2003)
Learned helplessness
Individuals with high self esteem seem to rely more on problem focused coping in chronic pain and are less depressed (Mruk 1999)
Personality psychological factor influencing coping
Hippocrates 4 humors
Type A and type B
Jung: thinking feeling, sensation, intuition
Myers-Briggs
Extrovert, introvert
Emotional stability/instability
Emotional stability- continuously striving for greater sense of emotional health, both intra-physically and intra-personally
Emotionally stable individual able to tolerate delay in satisfaction of needs, frustration, able to engage in long term planning and capable of revising his expectation in terms of demands of the situations
Emotional instability- trait characteristics of rapid, sometimes exaggerated changes in mood, strong emotions or feelings (uncontrollable laughing or crying or heightened irritability or temper)
Personality trait and disorder EI 2% of the general population and 10% of psychiatry outpatients
Resilience: Rutter 2012
Resilience is not a general or stable characteristic nor is it solely an outcome of adaptation in individuals or systems
Resilience is a complex process that manifests at specific moments in order to face certain circumstances
Resilience is inferred from the dynamic interactions of their components of risk and adaptation
Resilience: individual differences in response to environmental threats
Impact of chronic illness
Emotional distress (general/disease specific)
Restrictions and disruptions to normal life
Learning how to manage the illness
New ‘tasks’
Changing risk factors to help prevent progression
Side effects of treatment
Loss of self
Impact on families
Community care increases pressure on families
Physical, psychological, social, financial consequences of informal caring
Objective and subjective burden
Caregivers needs (often given low priority)
How can we help
Information provision
Social support
Self management training
Stress management training
Psychotropic medication or formal psychological therapy eg cognitive behavioural therapy CBT
Aims of coping interventions
Reduce distress
Help to manage illness effectively
Minimise impact of illness on daily life
Prevent progression and minimise risk of further health problems
Each intervention may have multiple benefits
Information provision
Good communication skills
Good interpersonal skills
Leaflets
Internet (incl forums)
Helplines
CDs/DVDs
Expert patients
Social support
Social isolation increases risk of mortality in many chronic illnesses
Can be to increase self esteem, advice, companionship, physical help etc
Self management training
Helps patients to gain ‘internal control’ over illness
Increase self efficacy and optimism
Adjunctive therapy
Management
Problem solving
Cognitive restructuring
Behavioural change plans
Relaxation and mindfulness
Positive self talk (self instruction training)
Often most effective with patient and carer present
