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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”.

1. Define the rationale for integrating psychological approaches

2. Insights from Behavioral Cardiology

3. Illustrate practical principles and interventions

4. Discuss feasibility issues

Goals

4

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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1. Define the rationale for integrating psychological approaches

2. Insights from Behavioral Cardiology

3. Illustrate practical principles and interventions

4. Discuss feasibility issues

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?

MOTIVATION EXECUTION MAINTENANCE

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

MOTIVATION EXECUTION MAINTENANCE

~70% of variation

MOTIVATION EXECUTION MAINTENANCE

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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Overcoming temporal discounting

• Make risk present-centered

• Make highly specific action plans

• Promote self-monitoring

• Automaticize the behavior

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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Overcoming temporal discounting

• Make risk present-centered

• Make highly specific action plans

• Promote self-monitoring

• Automaticize the behavior

• 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)

Overcoming temporal discounting

• Make risk present-centered

• Make highly specific action plans

• Promote self-monitoring

• Automaticize the behavior

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

MOTIVATION EXECUTION MAINTENANCE

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.

Arozanski@chpnet.org