How to alleviate patient anxiety about ICDs

A six-week online training course centered around living with an implantable cardioverter-defibrillator (ICD) helped alleviate anxiety in heart failure patients who were apprehensive about their devices.

Study head Stefan M. Schulz, psychologist Paul Pauli and a team at Comprehensive Heart Failure Center Wurzburg and Julius-Maximilians-Universitat Wurzburg in Germany designed the course for individuals with heart failure who were struggling mentally with the idea of an ICD. While ICDs undoubtedly save lives, they also issue painful shocks that serve as a reminder to patients that they wouldn’t be alive without their implants.

Those reminders can exacerbate the psychosocial stress already prevalent in patients with ICDs. In the European Heart Journal, where Schulz et al. published their findings, the authors said anywhere between 13% and 38% of ICD patients experience anxiety, and between 13% and 33% feel depressed.

“Current guidelines recommend assessment and treatment of psychosocial distress in ICD patients,” they wrote in the journal. “Traditional concepts such as self-help groups, individual face-to-face and group therapy have proven efficacious in ICD patients. However, screening is rarely performed in clinical practice and treatment options including psychotherapy and psychotropic drugs are inaccessible to patients with limited mobility or of limited value.”

A webcast system and telephone counseling improved those issues in a study of patients under 65 years old, but Schulz and colleagues said it was unclear whether a digital approach would also benefit older adults.

The team screened more than 1,200 patients in Wurzburg and six other German centers for the study, which ultimately enrolled 118 participants in their forties through late sixties. Half were randomized to a control group with no intervention, while the other half participated in six weeks of web-based training.

Schulz moderated the online sessions, which patients virtually attended in groups of 10 to 20 every week. Study participants were provided with a password that allowed them log in anonymously during sessions as they asked questions, talked to other patients in a discussion forum and participated in weekly focus topics.

The focus of the first week’s course was getting acquainted with the platform, but subsequent weeks explored the idea of living with an ICD, managing depression and anxiety and preparing for the last phase of life.

“Many patients had enormous knowledge gaps, which often give rise to fears,” Schulz said in a release. “For example, some patients were afraid to cross the barriers in the entrance doors of large stores because rumors are circulating that the electronics are switching off the defibrillators. In reality, there is no problem.”

The groups tackled difficult questions in their forums, like what happens to a patient’s defibrillator once they die, whether they should ever switch it off and what exactly they’re “allowed” to do while implanted with an ICD. Schulz said they even talked about writing or rewriting wills to alleviate some of the anxiety associated with future uncertainties.

The fifth and sixth weeks of the program were more participant-driven and focused on defining patients’ individual agendas for everyday life with an ICD. Schulz said the research team deliberately put an end to the program after a month and a half, “otherwise the temptation to postpone important questions would be high.”

Schulz et al. assessed the psychosocial status of study participants before and after the six-week course and one year after. They said it was immediately clear participants benefited from the training, and one year on those who completed the online modules were far better off than those who didn’t.

“This impressively shows that during the six-week training, the patients acquired competence in how to deal with anxiety,” Pauli said in the release. “We have sown a seed for something that grows when it is needed. The patients were sensitized to certain problems and later remembered the tools we gave them.”