Most physicians did not receive formal training to look at cardiovascular disease and mental health together. However, the more we not only talk but truly listen to our patients, we see the direct relationship between these two aspects of well-being. As our medical understanding of mental health continues to grow, treating the whole patient climbs the list of priorities related to improving long-term outcomes.
Independent cardiologists play a crucial role in this process. Our opportunities for long-term— and in some cases even multigenerational—patient-clinician relationships provide a strong foundation for delivering more holistic care. At the same time, physicians and administrators may wonder how to provide this type of integrated care within a busy practice. I can humbly offer a few suggestions from our experience at Samuel Family Cardiology.
The intersection of heart and mind
Like many cardiologists, I divide my time between a doctor’s office, inpatient hospital settings and multiple cardiac catheterization labs. That means I balance my time between technically challenging minimally invasive procedures, interpreting the results of cutting-edge imaging, and interacting with patients during medical evaluations. In all of these interactions, I’ve learned that the physical state of a patient’s heart represents only part of my focus when it comes to creating a treatment plan.
In my opinion, no hard line exists between heart health and mental health. Biological processes, like those involving neurotransmitters and hormones, influence both the heart and the brain to influence a person’s overall function.
Mental health conditions can affect heart health, and vice versa. I've seen countless patients presenting with shortness of breath, a racing heart, dizziness or chest pain. Countless times, this does not stem from a current or impending heart attack, but rather from the physical manifestation of depression, anxiety or any number of underlying issues related to mental health.
Mental health issues and substance use can limit a patient’s ability to make health-positive decisions and follow through on their care. Similarly, the demands of caring for their cardiovascular health can easily trigger or worsen a patient’s mental health experience.
Bridging the physical-mental health gap
While addressing mental health remains paramount to providing holistic care, integrating this care into a treatment path can feel unfamiliar and risky for most of us. Cardiologists may wonder, in the absence of structured training, how can I help?
In our experience, patients may not need their cardiologist to wield mental health expertise. They do, however, need their cardiologist to recognize their needs for specialized care and point them toward the right provider.
A collaborative approach to integrated care
In our practice, we started to bridge the gap between heart health and mental health by strengthening the doctor-patient partnership. I offer patients my best assessment of their clinical situation based on science, technology, and my efforts to not just hear, but also truly listen. With test results and clinical data clearly explained, we collaborate to set goals for where the patient wants to go and how we will work together to get there.
This collaborative approach enables us to look beyond solely the scientific aspects of care to the physical, social and economic environments that affect a patient’s well-being. We must consider these social determinants of health (SDOH) to create an effective healthcare strategy.
For instance, lacking reasonable access to affordable, fresh food can make it hard for a patient to change their diet. Patients who experience factors that worsen substance abuse, such as toxic relationships or economic instability have difficulty adhering to even the most carefully curated treatment plans.
Although the specifics differ for each person, many need to make major changes to maximize their chances for both successful recovery and maintenance of long-term cardiovascular health. When mental health concerns go unaddressed, patients can regress into unhealthy patterns around food and physical activity. We strive to empower our patients to make necessary changes without undermining their social support systems or leaving them alienated from the people they love.
Connecting with colleagues in the field
As I navigated patients’ physical and behavioral symptoms in context with their SDOH, I soon realized I needed to bridge my own knowledge gaps about mental health. In working to encourage patients to make healthy choices without putting up barriers against the people around them, I knew I needed to break down my own. As such, I reached out to colleagues in the field for advice to deepen my understanding. I also sought new ways to discover mental health resources I could share with patients.
Through this process, I discovered Mosaics of Mercy, a nonprofit organization in my community that helps people connect with mental health and substance use recovery services. Mosaics makes use of licensed Mental Health Professionals to maintain an evolving database of vetted service providers and personally connect our patients to the assistance they need.
Enhancing clinical workflows
From a practice workflow perspective, cardiologists must normalize talking with patients about mental and cardiac health.
In our practice, we either formally or informally use the PHQ-2 screening tool for depression and anxiety, which asks:
- Have you felt down or depressed or hopeless in the last two weeks?
- Have you been bothered by having little interest or pleasure in doing things?
The answers to these questions provide a framework for understanding a patient’s capacity to manage the necessary changes for their treatment, recovery and ongoing health. When needed, we can shift treatment and health-habit recommendations to better meet the patient where they are, and more clearly help them find the path to where they need to be. Additionally, we can make the necessary referrals to more specialized services as necessary.
Leveraging a purpose-built technology platform
The right operational partner can help independent cardiology practices deliver more holistic care while reducing administrative burdens for their staff. Alongside CardioOne, we adjusted our EMR to integrate mental health measures within our practice workflow.
We can specifically make use of existing EMR features to generate a referral letter to a mental health specialist in under a minute by populating a template with information from the patient’s medical record. This allows for easy customization of the patient’s story and provides clarity to the person on the receiving end.
These changes were fast and easy to implement—just another example of how feasible it can be for independent cardiologists to bring mental health into their care delivery.
Delivering meaningful shifts in cardiac care delivery
The Surgeon General’s Report in 1964 linked smoking to high rates of heart disease, and set in motion a movement to positively affect the cardiovascular health of millions of Americans. Six decades later, we can unleash a similar sea change by unifying physical and mental health in our cardiology practices. We believe simple, meaningful shifts in our care delivery systems will directly impact our patients’ ability to make life-saving and life-sustaining choices for themselves and for generations to come.
Dr. Paulraj Samuel MD, MPH, FACC, FSCAI, is a CardioOne physician partner. He’s board-certified in Cardiovascular Disease and Interventional Cardiology. He partners with his father, Dr. John E. Samuel, to run Samuel Family Cardiology. He divides his time between his practice’s outpatient sites and cardiac cath labs at Memorial Hermann (Northeast and The Woodlands campuses) and HCA Houston Healthcare Kingwood. He’s a graduate of Baylor College of Medicine.