ICD Implant Commonly Brings Anxiety, Depression

New-onset anxiety and depression are frequently seen after a first-time implantable cardioverter-defibrillator (ICD) implant, Danish researchers confirm.

Within the first 2 years, clinical levels of anxiety and depression were recorded in 14.5% and 11.3%, respectively, of patients who had been free of such symptoms prior to receiving the device, Susanne Pedersen, PhD (Odense University Hospital, University of Southern Denmark, Odense), reported recently during the virtual European Heart Rhythm Association Congress 2021.

“The take-home message here is that it is insufficient if we only screen ICD patients [for these symptoms] at baseline,” because these cases would be missed, she said. “And we know that anxiety and depression are risk factors for premature mortality, but also cardiac arrhythmias.”

The most-important way to address this issue is to educate patients about the possibility that they will feel anxious after device implantation and about how to manage it, according to Leah Brock, LMSW (Great Lakes Teletherapy, Ann Arbor, MI). Until recently, when she opened up a private practice, Brock worked as a clinical social worker in the outpatient clinic at Michigan Medicine’s Frankel Cardiovascular Center in Ann Arbor, helping patients navigate their lives after device implantation.

To prevent anxiety and depression from taking hold, it’s critical that patients get back to their normal activities as soon as possible and don’t avoid doing things out of fear of their condition or the device, Brock told TCTMD.

“After they get their implant, their brains are going to tell them: lay low, do nothing, let your heart rest, don’t get your heart rate up,” she explained. “And they have to be instructed to be mindful of those messages, but to not take them too seriously, and also understand the roots of anxiety and how their brains work around anxiety. And all of those education pieces have to come first and foremost. A person has to understand their brain’s role in adapting to their device.”

Younger Age, Type D Personality Increase Risks

Prior studies have shown that about 20% of patients with an ICD have anxiety and depression, but little is known about the development of these conditions after implantation, Pedersen said.

For this study, she and her colleagues examined data from the prospective, observational DEFIB-WOMEN study on 1,040 patients who received a first-time ICD implant at one of five centers in Denmark and did not have clinical anxiety or depression at baseline. Demographic and clinical data came from the Danish Pacemaker and ICD Register.

Participants completed questionnaires on anxiety, depression, and quality of life at 3, 6, 12, and 24 months, and an assessment of type D personality, which has been associated with poor outcomes in patients with CVD, at baseline. People with this type of personality, Pedersen said, are “usually bogged down by negative emotions, but also not willing to share them with others.”

According to these evaluations, roughly one in every seven patients developed anxiety during follow-up, with about one in every nine developing depression.

Younger age, type D personality, and poor physical functioning were risk factors for both anxiety and depression. Being married or having a partner and having a secondary prophylactic indication for ICD implantation were additional risk factors for anxiety, whereas smoking was associated with depression.

Brock said she’s not surprised about any of these risk factors. In particular, it makes sense that younger patients would be more distressed after receiving an implantable device, because they’re generally more active than older patients, meaning that any real or perceived restrictions would have a greater impact, she said. “They want their freedom. A younger person doesn’t expect to have a lot stand in their way of accomplishing things they want to accomplish, and in the time frame they want to get it done. So it’s an infringement on freedom for a young person more so than for an older adult.”

A person has to understand their brain’s role in adapting to their device. Leah Brock

As for patients with type D personality, Brock said “a distressed personality is just going to have less capacity to tolerate the potential that their device carries for causing a stressful event, a shock. They’re already feeling powerless, and we’re implanting them with a device that they fundamentally have very little control over. . . . It would magnify their sense of lack of control.”

The finding that patients in relationships were more likely to have anxiety runs counter to some prior research showing that having that support can be beneficial for patients with heart disease, Brock said, speculating that this different result could be reflective of the partner’s concerns. “They’re basically projecting their anxiety onto the patient, and then the patient gets a double dose of fear and subsequently has to react to that fear, and they often do so in maladaptive ways such as avoiding things or overly preparing.”

Tackling the Problem

When it comes to preparing patients for the possibility that they’ll feel distressed after receiving an ICD, Brock said, “I think the device industry can do a better job creating programs that talk to the patients about these devices prior to implant as a means of giving a patient more control over whether or not they want the implant, and then secondarily how to live successfully with it. This matters, as one element of poor coping following an implant is how much control the person had over receiving it.”

Patients who develop anxiety or depression despite education will want to talk to their cardiologist or primary care physician about the symptoms to discuss whether medications would be appropriate, and then should seek treatment from someone familiar with anxiety and depression, Brock said. She noted that cognitive behavioral therapy can be an effective way to deal with these issues, because it challenges the thoughts that are holding patients back.

“I think a take-home message is to not ignore the mental health aspect of a patient’s needs as far as adjusting to having a device,” Brock said. “The mental health side of things can be as important as the physical in both the preimplant and postimplant phases.”

And she reiterated that “we need to pre-educate these patients better, focusing beyond just their physical health, teaching them how to live successfully with the device as soon as they get home.

“Ideally, we would also have providers follow them more closely in their early recovery to discuss not just their physical symptoms, but also their coping and adjustment,” she continued. “Then we can impact their behaviors early on to foster their ongoing success. We also can't forget to amp up support of mental health when they have shocks or setbacks, as these can dramatically affect their functioning. So we really want to be more deliberately hand-holding these patients before they even get their implant, with focus on their bodies, but also their minds.”