Psychosocial risk factors are increasingly being recognised as predictors of health outcomes, including mortality, in individuals with cardiac conditions[#grewal-k-gravely-witte-s-stewart-de-et-al.-2011] and can also influence adherence to recommended treatment.[#richardson-lg.-2003]

A psychosocial assessment helps the clinician to provide individual, focused interventions and to identify barriers to a patient's self-care. Including psychosocial interventions to standard cardiac treatment regimens reduces mortality, psychological distress and certain risk factors in individuals with cardiac conditions.[#aldcroft-s-taylor-f-blackstock-f-et-al.-2011]

Psychosocial interventions should be tailored to individual and caregiver needs according to issues identified in the psychosocial assessment. If the clinician considers that the particular psychosocial intervention falls outside his or her skill level or qualification, the patient should be referred to a suitably qualified healthcare colleague for further review.

Psychosocial counselling should be made available to all individuals with a cardiac condition and their families in order to reduce the impact of psychological distress. Different types of distress will require different types of treatment. Psychotherapy for emotional and behavioural problems may be provided by psychologists, psychiatrists, social workers, occupational therapists, and counsellors.

• Nature of the issue: What symptoms/concerns are identified by the individual, family and carer?
  • Extent: How long has each concern been present and how does it affect current functioning?
  • Severity: How intense are the symptoms in regard to daily functioning?
• Medical history: Document current and historical medical concerns including any diagnoses, surgery and accidents
  • Obtain: A copy of current medications from the individual or health team
  • Note: Contact details of all health professionals involved in the care of the patient
• Substance use: Assess whether the individual is currently using any substances that may interfere with functioning and management of their cardiac condition

• Family situation: Identify family members living with the individual and the location of those elsewhere
  • Consider: The extent of family support available
  • Note: Any presence of tension in relationships with family members, including any family estrangements. This information identifies significant others who will be impacted upon by the individual’s condition and identifies possible sources of support or stress
  • Record information: In either narrative form or by using a genogram
• Relationship status: Note whether the individual is single, de facto, married or widowed, etc.
  • Note: The level of satisfaction within the current relationship and any concerns relating to sexual difficulties. Discussion of sexual concerns is of significant importance to individuals with cardiac conditions and is often rated as being poorly considered by clinicians[#medina-m-walker-c-steinke-e-et-al.-2009]
  • See section on resuming sexual activity
• Communication: Assess the individual’s ability to comprehend written and verbal communication
  • Confirm: What the person’s first language is
  • Note: If they individual require reading glasses or a hearing aid
• Cultural connections: Assess whether the individual identifies with a specific culture or ethnicity, and how this may affect the delivery of health care interventions
  • Confirm: What type and frequency of cultural/ethnic activities the individual currently engages in For example, does the individual engage in customary fasting or is there a need for gender segregation during exercise?
  • Assess: Whether the affiliation adds to their current difficulties or helps them to cope with their current circumstances
• Religious/spiritual connections: Note whether the individual has any religious or spiritual affiliations, and how this may affect the management of their cardiac condition
  • Consider: Which religious/spiritual activities the individual currently engages in, if any, and how these impact on their heart condition. For example, certain religions prohibit some medical interventions such as blood transfusion, while other religions follow strict dietary regimens that may not be aligned with the usual heart health dietary recommendations
• Social involvement: Enquire about an individual's social connectedness. Lack of social connectedness has been linked to an increased risk of depression, anxiety and physical disability
  • List: Any interests and involvement in sports, and recreational or community programs
  • Ask: If such interests assist them to cope with current circumstances. If the individual is not currently involved but would like to return to such activities, helping them to identify and resolve barriers to their return can facilitate this goal
• Employment and education: Identify the highest education grade completed, and current and past work history
  • Discuss: What does work mean to the life of the individual and their sense of identity
  • Ask: What is their perception of return-to-work readiness and do they see any barriers to this. If their previous employment position still available
• Financial issues: Identify any financial issues
  • Discuss: If currently employed, is the individual accessing leave entitlements If they are aware of possible entitlements through income protection insurance, superannuation and Work Cover. If they are aware of and receiving the correct Centrelink entitlement. See www.humanservices.gov.au for further information.
• Transport: Note the patient's current transport options
  • Ask: If the individual received medical clearance to drive and advised the licencing authority of their medical condition. If unable to drive, do they have access to transport through an informal support network or carer. Is public transport accessible and safe for the individual’s use. If they eligible for community transport
• Functional status: Assess any difficulties attending to daily living tasks such as personal hygiene and grooming
  • Note: If they prepare meals and manage domestic tasks. If they access informal support networks such as family or friends to provide assistance
• Accommodation: Note the patient's current housing arrangements and assess whether there are any issues of concern
  • Consider: If the cardiac condition has caused financial insecurity in regard to accommodation. If their present accommodation meets the individual’s needs at their current functioning level as well as if their health deteriorates
• Legal considerations: Identify any presenting or anticipated legal issues for the individual or carer
  • Discuss: Whether the individual has a will, guardian, Advance Health Directive or Enduring Power of Attorney. If so, obtain contact details of any appointed persons and note whether the Enduring Power of Attorney is active or inactive
  • Note: The individual’s wishes in respect to organ donation and funeral arrangements?
  • Consider: Other factors that may impact on the delivery of health care such as immigration status, domestic violence orders, court proceedings, the individual’s physical and mental health capacity and evidence of informed consent
• Community services: Obtain contact details and assess the nature of any formal support being used by, or available to, the individual
  • Ask: What is used or available, by whom, how much and how often
• Carer considerations: Assess the nature of any informal care and support available to the individual
  • Note: What support is available, by whom, where carers live, how much care can be provided and how often
  • Ask: About caregivers’ perception of the situation and of their own wellbeing, their own support networks, either formal or informal

• Cognition: Cognitive impairment has been observed following certain cardiac procedures such as coronary artery bypass graft (CABG), valve surgery and angioplasty, and people with chronic heart failure (HF) appear to have increased rates of cognitive impairment[#pressler-s-subramanian-u-kareken-d-et-al.-2010]
  
  Cognitive decline can affect short-term memory and executive functioning such as speed of processing, attention and visuospatial reasoning. Clinicians should be aware of this possibility in individuals with cardiac disease. If screening suggests impairment, consider referral to a specialist for formal testing
   
• Psychological distress: For details on assessment approaches see psychological distress and quality of life. Common forms of psychological distress include depression, anxiety, anger, suicide ideology and post-traumatic stress
  
  Patients with heart disease should be fully assessed for the presence of these distressing emotions. While these emotions can be normal reactions to challenging experiences, sometimes they can become so intense that they affect normal functioning or become health risk factors. See video on Coronary Heart Disease: Moods and Emotions to hear patients explain about the impact of psychological distress
   
• Coping strategies: People cope with difficult situations in many different ways. Based on their coping strategy, individuals can be loosely categorised as 'Monitors', 'Blunters' and 'Avoiders'

Monitors

• Monitors are hypervigilant about their health, seeking information from a wide range of sources. They ask a lot of questions during consultations and cope best when presented with information about their health
• Monitors may become distressed if the explanation about their health lacks detail

Blunters

• Blunters prefer to take in just the main facts about their health rather than worry about exploring the details. They often downplay the psychological impact of threatening health information and are less motivated to undergo health screenings
• Blunters can become distressed and overwhelmed if given too much information so it is important to assess their needs and then tailor the amount of information provided

Avoiders

• Avoiders cope with difficult situations by avoiding experiencing unpleasant thoughts, emotions or situations. They use cognitive or mental avoidance, emotional avoidance or behavioural avoidance
• Cognitive avoidance includes distracting oneself through excessive TV watching, or actively trying to suppress unpleasant thoughts or memories. Emotional avoidance includes feeling emotionally numb, or frequently engaging in fun activities aimed at drowning out any negative feelings
• Behavioural avoidance may include avoiding certain people, such as health care providers or places, such as hospitals
• Avoidant coping strategies are associated with anxiety and poor adherence to recommendations. Even if Avoiders value an appointment, they may miss it because their general coping strategy avoids anxiety that way. Missing medication or exercise may serve the same purpose
• With Avoiders, it is best to take a very empathic approach, by showing understanding of individual’s challenges and, if necessary, refer to a mental health professional for anxiety management

Your overall assessment should include:

• A summary of presenting problems, symptoms and level of functioning
• Analysis of the patient’s current situation
• Your conclusions, which should include:
  • Treatment need
  • Level of care required
  • Services required
  • Barriers to accessing services
  • Other information relevant to the management of the individual's cardiac condition
• Recommendations for specific services
  ​You should also:
  • Discuss with the individual his or her goals and priorities for intervention
  • Acknowledge the individual’s strengths and use these as platforms to build coping and problem-solving skills and to develop a more positive self-concept
  • Identify barriers to recovery and consider these when negotiating treatment goals and measureable outcome
  • Record the agreed plan of action