12 furthermore the crsp professional can provide

12
Furthermore, the CR/SP professional
can provide significant input into this evaluation
through direct observation and documentation
of patient behaviors that may contribute to psy-
chosocial distress.
Need for Medication
Is the patient in need of evaluation for psycho-
tropic medication and psychotherapy? Between
30% and 50% of cardiac patients suffer clinically
significant levels of anxiety or depression. These
symptoms dissipate spontaneously within 6 to 9
months in many patients. However, depressed
patients remain at a higher level of cardiovascular
risk until remission or dissipation of the symptoms.
Hence, CR/SP professionals should very carefully
consider medical evaluation of the need for anti-
depressant or anxiolytic therapy for a patient who
has a history of anxiety or depression, who exhibits
an elevated score on a questionnaire assessing
negative affect (e.g., Beck Depression Inventory,
13
Symptom Checklist-90-Revised [SCL-90R],
1
Profile of Mood States,
15
Center for Epidemiologic
Studies Depression Inventory [CES-D],
16
Spiel-
berger State-Trait Anxiety Inventory
17
), or whose
current functioning is significantly compromised
by any combination of the signs and symptoms.
While it remains unclear whether pharmacologic
treatment of psychological distress decreases over-
all mortality, there is evidence that it can lower
psychological distress as exemplified by the use
of selective serotonin reuptake inhibitors (SSRIs)
for the treatment of depression.
18
Tobacco and Alcohol
Patients who continue to smoke following a coro-
nary event experience twice the risk of death as
their counterparts who quit. Efforts to promote
smoking cessation begun during the inpatient stay
appear to be particularly effective.
19
Appendix K
presents a questionnaire that may be useful in
eliciting a comprehensive smoking history.
It is estimated that 25% of patients in the hospi-
tal abuse alcohol or are alcohol dependent.
20
The
increased risk associated with excessive alcohol
intake and other substance abuse makes this an
important area for assessment. Persons abusing
substances routinely downplay the severity and
effect of their use, making it all the more difficult
to uncover. The CAGE Questionnaire (appendix
L) has a particularly helpful set of standardized
questions that can be used during a clinical inter-
view in both the inpatient and outpatient settings.
Adherence: Attendance, Risk Factor
Modification, and Medication
Adherence to recommendations including CR/
SP program attendance, risk factor modification,
and medication is essential for addressing CVD.
However, several of the factors discussed earlier,
such as depression, can impair adherence. Hence,
early identification and treatment of significant
psychosocial distress is essential in optimizing
patient outcomes.
Interventions
Inpatient CR/SP services present an early oppor-
tunity to assist transition into the home environ-
ment while providing support, education, and
counseling related to those areas identified in
guideline 8.11.