How do we heal the sick at heart? : a review of psychotherapy for stress dysregulation and depression to decrease cardiovascular risk

  • Dr Loyola McLean, SWAHS; Consultation-Liaison Psychiatry, RNSH, Sydney; Discipline of Psychiatry, Sydney Medical School,University of Sydney, Australia
  • Ms Vicki Maddison, Private Practice, Australia
  • Prof Christopher Tennant, NSSCAHS ; Discipline of Psychiatry, University of Sydney, Australia
  • Dr Marie-Christine Morel-Kopp, Dept of Haematology and Transfusion Medicine, RNSH, Sydney, Australia
  • Mr Walter Chen, Dept of Haematology and Transfusion Medicine, RNSH, Sydney, Australia
  • Dr Christopher Ward, Dept of Haematology and Transfusion Medicine, RNSH, Sydney; Sydney Medical School,Universtiy of Sydney, Australia
  • Dr Marie-Therese Proctor, Children's Hospital Westmead, Australia
  • Prof Geoffrey Tofler, Dept of Cardiology, RNSH and Sydney Medical School, University of Sydney

Objective: Depression both causes and complicates cardiovascular disease. However the treatments, especially the psychotherapeutic interventions and integrated treatments, that will be most effective and for whom are still to be clarified. This paper will address an approach to this question for future trials.
Methods: We review some possible dysregulations of the stress response that might predispose to depression and to cardiovascular disease (CVD) and the current evidence for addressing them therapeutically. We examine the patterns of breakdown of stress management strategies that we observed in our prospective study of depression without known CVD where we used attachment theory as a means of formulating the presentation and the treatment. We use our experience with these community outpatients with major depression, in whom we were able to alter aspects of cardiovascular risk, including platelet hyperreactivity and a prothrombotic profile, to inform a review of the use of psychotherapy in trials to decrease cardiovascular risk. We include a discussion of approaches to the affective dysregulations associated with Type D personality, a personality group at known risk of CVD and its complications. We review the comorbidity with other illnesses associated with stress dysregulation and argue for the importance of addressing the top-down management of stress regulation.
Results: The literature and our experience would suggest that the entrenched, extreme and often unconscious nature of the stress management strategies present in those with depression may require more intensive psychotherapies and/or better integrated treatments than have often been used to date to alter cardiovascular risk. If altering the ongoing psychophysiology of the stress system is the target, an intensive and integrative approach is logical, especially for those with high risk strategies such as Type D personality.
Conclusions: As we seek to improve outcome for CVD and depression, it is timely to evaluate the role of integrative treatments and psychotherapies (such as psychodynamic therapy and mindfulness meditation) in effecting change in entrenched stress response patterns by more sophisticated treatment arms in future trials.