Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr Warrick Bishop and welcome to my podcast and videocast station. Today I'm absolutely delighted to have as a guest Dr Ralph Ilcheff, who's Director of Liaison Psychiatry at the Royal North Shore Hospital in Sydney. Welcome Ralph, how are you? I'm well, thank you Mark Warrick and thanks for having me on. Look, I'm so pleased to have the opportunity to pick your brains about... the process of recovering from a cardiac event, because I think that mental side of it is just so important. So I mean, the, my imagination is that as a liaison psychiatrist from time to time, you actually confront people who have just had an event. What's your read or feel with them, Ralph? Well, I think psychiatrists maybe think about it a bit differently from cardiologists. I work in a, a large teaching hospital. And for those who don't know what a liaison psychiatrist is, it's a psychiatrist who sees people who have both medical and psychiatric problems, I suppose. So a large group of people that we see are people who have been hospitalized for a cardiac event and who are having some kind of issue with adjusting to it. And that issue might be acute anxiety. It might be low mood. But sometimes it might be a pre-existing mental health problem that's been stirred up or worsened by by a cardiac event. So I guess, you know, as I say, as a non-cardiologist, I come to it almost as cleanly as a patient does. We don't think about hearts very much. They're just these pumps that kind of work in our chest and then suddenly something happens and they stop working or they stop working properly and you get this terrible shock to your system, this very profound... sense of your own mortality and you're in the hands of these medical and health professionals and you've got to try and make sense of this extraordinary thing that's happened to you. We know that it's very, very common for people to have kind of acute what are called adjustment reactions, anxiety or mood problems, things that are sort of collectively known as cardiac blues. They happen very commonly. And for most people, those things are brief, self-correcting things that don't really need any intervention. But about 20% of people develop more significant mental health problems as a consequence of a cardiac event, often depression or an anxiety disorder. Some people can even have some elements of a post-traumatic stress disorder because of the threat to their... life has been so profound. And we get involved with those people, of course. But I think, you know, it's a massive event, I think, for anyone. And I'm actually surprised by how well and how flexibly and adaptably and humorously the great majority of people react to these events. So one of the things you mentioned, a term called an adjustment disorder, and obviously I'm not a psychiatrist and you won't know what that means, but I imagine that's a psychological process of responding to an event. But one of the questions I was going to ask, and I've always thought this to be the case, is that when I see people after some sort of hard event, I'm wondering if they're actually going through some sort of grieving process with the loss of good health or the loss of well-being or the loss of immortality. being the thing that they grieve. And I can't even remember the stages of a grieving process, but there's sort of anger and why me and denial and so forth. Can you speak to that? Yes, of course. I think that what you said is exactly right. I mean, there's nothing like an event happening to your heart to remind you that actually one day it's going to stop. So that's a very profound recognition of your own mortality. And that's not something that people think about. unless they're required to or made to. So a cardiac event, I think, almost always has a huge impact on a person. The majority of people just have this kind of acute reaction. They deal with it well with the support of the health professionals they're working with and their families and they recover well and go on with their lives. A significant group of people have these things that I was talking about, these adjustment reactions, which are a little bit more than that, where they're sort of knocked out of orbit a bit longer by marked anxiety or by low mood, so either worry or sadness essentially, that are just a bit more intense and a bit more prolonged and a bit more debilitating than usual. Most of those people don't need specific psychiatric help, but they might need to see a psychologist or a counsellor or talk to their GP. And for most of those people, in fact, engagement in a well-run and well-thought-out cardiac rehab program is probably the very best thing that you can do for them. And then you get this other group of people who get a more marked amount of debility associated with their cardiac event where they develop. Severe depression or severe anxiety or PTSD. Now, those sort of people are really important to follow up because we know that, for example, untreated depression can affect the outlook after a cardiac event and increases the impact that it has on a person's life. And it's not as simple as just kind of chucking an antidepressant at them or some counselling at them. They really need a thoughtful and sort of holistic approach to their rehabilitation to ensure that they have good outcomes. Ralph? When these people have a particularly problematic cause or a particularly rough road after their event, are there sort of markers that are apparent before the event that we should be aware of as cardiologists? So is there a pre-morbid sort of person, character who's going to have more troubles or is it quite variable? Is it related to the extent of the injury or the event? a heart attack versus chest pain versus cardiac arrest? Is there? What's your thoughts on that? Look, it's a great question, Warrick. And in fact, you know, some people are now saying that people who have a booked... cardiac procedure should actually have some form of prehab. They should really be kind of looked at in terms of their risk factors prior to cardiac surgery or cardiac procedures because there are some things that we know put people at greater risk. The most obvious one, of course, is having had a past history of depression. past history of an anxiety disorder or people who are known to have another mental health condition or for example an alcohol use disorder or a substance use disorder so if you've got a history of mental health issues in the past then you're definitely at increased risk after a heart attack or after a cardiac event I should say there used to be a lot said about particular personality types about type A and about various other personality types, that hasn't really been fantastically well borne out in the literature. And I think it's – so that's probably, I think, misleading. So probably along with a – The other thing, there are certain things we also know put people at risk. People who have had more adversity in their life and more struggles in their life are more likely to have problems. People, as I've said, with a history of depression or anxiety are more likely to have problems. But after that, it's a lot to do with the event itself and how severe it is and how grave the threat to their sense of themselves was. how prolonged the hospital stay was, what they've been told about their prognosis and how smooth or complicated their recovery was. And all those things will have a big impact too. Look, I'm going to throw something out there and it's just an observation from the clinical exposure I've had over 20 odd years of dealing with people in this space. And I almost get the sense that women deal with this with these challenges or with these events out of the blue differently to men. And I'm not sure who does better or worse, but I just get the sense there's a difference in the way men and women respond to these sort of cardiac events. We were talking about this earlier and you said there wasn't a great deal of literature in that space, but what are your thoughts and any comments around that? Well, look, I think... It's certainly possible that men and women react differently. We know that generally, for example, over a lifetime, women are more likely to experience depression than men are and are more likely to experience anxiety, whereas men are more likely to experience substance use disorders. So there are certain mental health conditions that are more common in men or women. And I think it's also true that the health system treats men and women a bit differently too. Historically, we haven't been quite as good at picking cardiac. problems in women or as men. It's known, for example, that the sort of chest pain that women get is often not quite as textbook as what we've been taught to understand is the chest pain of coronary artery disease. And there are other considerations that can make their treatment course in hospital a bit more complicated than men. So sometimes it might actually be... them responding to system issues as opposed to kind of vulnerability factors. Off the top of my head, I don't know whether the rates of depression or anxiety are higher in women than in men. I don't imagine that there's enormous difference because I've certainly seen plenty of people of both sexes who've suffered with depression and anxiety after cardiac events. But I think there are... a variety of things that will have an impact. I think, and of course, the symbolic impact of a loss of role to people is really important too. And historically, these men have tended to be a lot more invested in their work. That's obviously different now. And having to stop work or adjust your work can have a big psychological impact. But of course, now that so many women also have really busy careers, that's less of a distinction. Look, one of the issues that's clearly different between the sexes is that of potential sexual function after an event. And I know my own experience with my practice that it's not uncommon for men to report some loss of sexual function, at least for a period of time after an event. And I think you can understand that for a number of reasons, obviously. There's drugs. Our drugs can... impact sexual function, but there must also be a fear of an event potentially occurring at any time and it must play on people's minds. Do you see much, do you have a role in dealing with patients in that space with difficulty with sexual function? And presumably that's different for men and women as well? Absolutely. I think, you know, certainly when I've seen concerns expressed. by both sexes, but probably the ones that come to mind most have been males who have been really worried about, both worried about resuming sexual function just because of their concerns that it might trigger another cardiac episode and also because of people who are having problems with sexual function, either with arousal or, in the case of men, with achieving an erection or ejaculating. And as you say, that can be due to all sorts of factors, including cardiac medications. And of course, for people who are on medications for their mental health, antidepressants can also have an impact on sexual function. So there are lots of reasons why it can be a bit of a minefield for people in the rehab period. And it's a really important part of recovering. healthy and full life. And it's probably something that isn't as fully followed up and monitored as it should be. It's a very important issue. And I think it is often skirted around and sort of pushed to one side, I think. But it's very important. Look, one of the other things that I think that I've again observed is the importance of having a solid and supportive, important other in your life, your partner. But there must be times when dynamics with the partner are stressed or strained or the partner themselves may unravel. But, of course, the benefit of having a strong partner is the support that they can offer as well. Would you like to talk about partner, family, kids, and maybe even sibs? Because, of course, one of my areas of interest is prevention. And if Mr. John Smith at 55 years of age has a heart attack, that's pretty young. The first thing I'd be asking is, have you got brothers or sisters? Absolutely, Warrick. I think that you touched on so many things there. I think that the amount of support that a person has around them is a really vital determinant of their psychological recovery after a cardiac event. there's evidence that it's equivalently important to how well their heart functions. So, you know, for those who have a partner, for that person to be supportive and encouraging is really important. For those who don't, then certainly the role of close friends, sibs, children, parents, it's really not something you want to be going through as an isolated person. You know, you really need to have... people on your side and of course for people who are in a couple um there's a profound uh reorganization of the dynamics of a relationship because a person has suddenly who's been an equal partner um it has suddenly become acutely unwell and is now in this patient role, in this sick or invalid role. And a lot of things have to be renegotiated during that recovery period. And then as they recover their strength, those things have got to be renegotiated back again. And then suddenly the partner who's been used to calling the shots for a while, it can sometimes be not that enthused about handing a whole lot of things back. So there's a lot to work through. And of course, as you mentioned earlier, the resumption of intimacy is a really important part of that for a couple. So I think there's plenty of areas to go through. We know that, as we mentioned a bit earlier, that attending a cardiac rehab program is really important for recovery and a lot of people don't proceed or persist or complete. these courses. And often that's, you know, there are all sorts of reasons. They want to go back to work or they just don't want to think about it or they hate being reminded of the fact that they've had this event. They find reasons why they don't want to complete a rehab program. And a partner who is strongly encouraging of the need to complete cardiac rehabilitation is a vital asset, I think. I've done some work. I've just done a bit of reading around the advantage of having a positive partner and there's no question i mean they've done um research on yes male partnerships and men with stable supportive wives just do better there's no question about that i don't know about other relationships, but there's no question in that space. Yeah, yeah, that's right. I mean, it's certainly a great test for a relationship, you know, everything being turned on its head and everything being made uncertain and there are financial and every other sort of stress suddenly comes into view. And so you get a sense of, you know, the metal you're made of and that your partner's made of at a time like this. So thanks, Ralph. One of the other things that I've... sort of tend to have observed or i think i've observed is a difference in the response that people bring to their event based on their age and or it almost seems like there's far more pragmatism and far more awareness of the transitory nature nature of life in our older patients who suffer events they just seem more phlegmatic about it, which I guess is understandable and the younger far more concerned, which I guess also makes sense. Do you see that? Yeah, I think that's right. I mean, I think you're constructing this narrative of your life as you go along. And if you're a 75-year-old guy who's had a heart attack and you recovered from it, you go, well, it's... kind of something that happens at my time of life, that's sort of all right. But if you're a 35-year-old guy who has a heart attack, then that's a very different story. Most of my mates are playing indoor cricket or riding bikes or going surfing, and here I am holed up in a cardiac ward. So I think it's this sense of incredibly premature mortality is very frightening. So I think that psychologically it's a much, greater event for a younger person, a person in their 30s, 40s, 50s. So that's definitely a predictor, I think. And I think that I see those sort of people being at particular risk and really needing the most intensive psychosocial and physical rehabilitation that we can offer them because I think that they're at higher risk of depression. And then in this horrible sort of circular movement, developing depression then worsens the outcome of their cardiac condition. And that's more complicated than it sounds because if a person who's had a cardiac event gets depression, unlike most people, you can't just chuck an antidepressant at them or send them off for successions of... cognitive behavioral therapy because that by itself is not actually that helpful it doesn't tend to improve cardiac outcome um you've got to treat their depression absolutely but it's got to be locked in with every other phase of their of of of risk reduction and you know improving their their their fitness and improving their diet and losing weight and doing all the things that are required as part of their cardiac rehab um and you know i think we should and for these for the younger people and certainly the yeah what do you want to say the under 60s or so who um i think They need to have a lot more resources put into their treatment. And an awful lot of cardiac rehab programs still don't have a strong psychological or psychosocial component to them. And I think that's definitely an area we could improve. Look, one of the things that I find myself involved with patients all the time is trying to get them to take their tablets. Take your medicine, I say. It's good for you. And they say, how long do I take it for, Doc? And I say, for life, and that's a double meaning. So please take it. So compliance issues, Ralph. Do you think that people have had a bypass, a major procedure with a big scar and aches and pains, do you think these people are psychologically better prepped because they had a greater impact than someone who's wafted in with a little bit of chest pain, gets a stand? Gets back to work a week or two later, you know, barely a hair out of place, maybe a puncture site in the wrist or the leg. Tell me about your thoughts on compliance and taking your medicine. Yeah, look, I think that's right. Medication adherence is a real problem. And the best thing for it is the quality of the therapeutic relationship they have initially with their cardiologist and subsequently with their GP. never underestimate the importance of explaining to them exactly what these drugs do and exactly why they're so important. And, you know, we're not just saying this to fill up the consult time and because we've got nothing else to do or because we want this drug company to take us away to a conference. We want you to take this pill because there's really, really good evidence that it will improve your outcome. And so I guess it's also... I think the pushback from the patient is a good reminder to us. Well, now, is this medication regimen as clean and efficient as it can be for this person? Are there any pills that we could get rid of? As you know, doctors are fantastic at prescribing medication and we're terrible at stopping prescribing medications and people just kind of accrete medications like barnacles over time. So every now and then someone's got to look at them and say, do you still need to be on that cholesterol drug? When do we check your cholesterol? I think you've got to be satisfied in your own mind that there's an absolutely powerful indication for them to be on that. medication, and then you've got to persuade them to stay on it. But adherence is a big issue, but obviously really important. Do you think the more profound nature of having your chest literally cracked open for bypasses focuses people's attention? Oh, yeah. Nothing like a thoracotomy scar down your chest to remind you that this is real, for sure. I wanted to ask you this as well. There's no question of the value of rehabilitation emotionally, but also physically and as part of the process of recovering. There's no doubt about that at all. But are you aware of any potential pitholes or traps within the rehab process? And I'm just going to mention that I've observed some patients who go along and they compare number of grafts, for example. six grafts and you know terry only had two i was clearly worse you know so there's a bit of a number of graft bragging goes on yeah yeah i would look like it like like i think like every um you know therapeutic group, there's always a risk that it'll develop an unhealthy dynamic that it will get kind of captured by some large personality that has his or her own ideas. And so I think that those groups have to be really well run and really well facilitated and people have to be reminded that everyone's story is different. And it's not actually that relevant whether that one person had four grafts and another person had two. There are lots of other really important factors here. So, look, I think you're right. But I think – but at least, you know, from my point of view, one of the great advantages of a rehab program is at least those people are being seen and reviewed and seen by sort of skilled health clinicians on a regular basis. And people will notice if people are – not coming to sessions or if they're not saying very much or, you know, there are some things that are predictors of a bad outcome and it can be, you know, people with persistent physical symptoms that don't settle down, people, you know, with unexpected reduction in exercise tolerance or that isn't accounted for on... from some cardiac factor, people who stop coming to sessions, people who just seem very kind of detached or whose mood deteriorates. And it's great to have a rehab program so that those sort of people get picked up and hopefully someone at least talks to their GP about some follow-up for them to make sure that they are getting the... the psychological and psychosocial support that they need. I think, of course, there are definitely risks whenever you get a group of people together, but I think that there's, and people do get competitive, but I think, you know, overall, you know, the rehab process is a really good one. Yeah, of course it is. There's no question. Look, Ralph, for someone who might be listening or has the chance to read this later because we'll transcribe it, Are there any signposts or flags or points that the individual who's gone through a cardiac event or the loved one of that individual should be keeping an eye out, something that would perhaps be the trigger for them to follow up with their GP? Look, probably the loved one especially because they're the ones who, you know, the person who's closest to the person, whether it's their partner or, you know, their partner. close friend or their parent or their child that's caring for them or whoever sees the most of them. There's a few things to be aware of and I think medication non-adherence is often a sign that a person's pretty disengaged from the process and getting a bit fatalistic about things and that can be a sign of depression. People who The symptoms of depression that people ought to be aware of, they occur in sort of three clusters. There's the emotional symptoms, of course, like sadness, teariness, social withdrawal, a sense of a foreshortened future, a feeling of pessimism and hopelessness about everything. But those emotional symptoms are just one part of it. There are also physical symptoms, which can be quite hard to tease out from the physical symptoms that people have just had a big cardiac procedure go through. Things like fatigue, loss of appetite, sleep disturbance, loss of sexual interest, loss of pleasure in ordinary pleasurable activities. And then there are also cognitive symptoms as well. And of course, it's not uncommon to have some problems with memory and concentration and thinking after a big... cardiac event, but people who find that they've got their senses, that their memory doesn't work very well, that they can't plan very well, that can also be a hint that depression is an issue. And of course, lapsing into behaviours that are obviously not good for them, like resuming a bad diet, resuming smoking, drinking too much, doing all the things, essentially. kind of passive-aggressively defying all the medical advice that they've been given is often a sign that a person's demoralized and getting quite depressed. And that's, you know, a good opportunity to try and have some sort of intervention to turn it around. And, you know, and your GP is a great place to start with that. Look, Brav, we're pretty close to the end of our time. We've covered an enormous amount of stuff, and I really appreciate it. And I've learned from you, as I'm sure the people listening have picked up some pearls as well. I don't want to put you on the spot, but was there anything in particular that you'd like to close off with or wrap up with? And no obligation, but if there's something, a parting remark that would work for you or something that you really want to underline, because this is an extraordinary moment in people's lives and an opportunity for us to think about it and do it better if we're aware. And I honestly have to confess, I don't think I've been on the ball as often as I should be, but you've focused me to pay more attention in that space, no question. Yeah, look, I think, you know, there's nothing like a major cardiac event to really make people try and have a reset in their life and try and do what they can to resume control of their life and improve their physical health, improve their relationships, think about the impact of depression and anxiety. Because we've talked so far about... heart disease predisposing people to depression. But it's important to know that depression actually predisposes you to heart disease. So people who've actually been living with depression are putting themselves probably at some kind of risk. I think your mental health is always something that you want to try and optimise as much as you can. So it's a great opportunity to really give yourself that sort of 20,000 kilometre service and have your mental and emotional health seen to. along with your physical health. But remember that there's never been a better time to have a cardiac event. Medicine has come such a long way. There are so many wonderful treatments available and more coming down the tube and that people should feel really confident that they've never been better placed to have a really good outcome from a cardiac event and to be... confident that they've got a lot of life ahead of them and that they should live it as well as they can. So thanks for that summary, Ralph. Just before we close, I'm going to wrap up with a plug for one area of rehab, which I think is incredibly important. And that is the role of exercise for not only things like blood pressure, things like, well, strength, mobility. sugar control insulin resistance but it's also good for mood and correct me if i'm wrong my understanding was that exercise can be as effective as a an antidepressant so what's your spin on that is that correct that's absolutely correct Warrick and in fact the news is all good uh any amount of moderately vigorous physical activity that you do is really good for mood and anxiety And the great news is it doesn't matter what it is. If you like weightlifting, that's fine. If you like running, that's fine. If you like playing golf, that's fine. Anything that gets you out and gets your heart rate up is really good for mood and really good for anxiety. And the optimal amount is about an hour a day or seven hours a week. Plenty of people can't do that much and that's also fine. And any more than that... you're very welcome to do if you enjoy it, but it doesn't confer any additional mood or anxiety benefit on you. But certainly regular physical activity is a fantastic thing to incorporate into your life purely from a mood and anxiety perspective. Well, look, we've covered heaps of stuff, Ralph. I really do appreciate your time. That last plug for exercise is excellent. So we will leave people thinking about that, but we've covered such a breadth of stuff. Ralph Ilchep, Director of Liaison Psychiatry at the Royal North Shore Hospital. Thank you so much for joining us. My pleasure. Thanks for having me, Warrick. All right. Thank you. Look, for those listening, I hope you've learned as much as I have. If you've got any queries or questions, please drop us a note at the info email. If you've got any suggestions for future podcasts, also please give us a note. Please look after yourselves. Thank you for being... sharing this podcast with me. Until next time, take care and please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
