Definitively Defibrillatorily Depressed

4. June 2012

The technology of implantable defibrillators has evolved to such an extent in recent years that false alarms occur only rarely. Those patients however who experience surprise violent electric surges several times a year often have to battle anxiety and depression.

In reality, the patient ought to be able to sleep peacefully, since there sits in his or her chest a lifesaver installed by a heart surgeon. This small current-pulse generator, via its sensor, detects ventricular arrhythmias; in a situation where an alarm signal is given, it is responsible for the shock that makes the heart pulsate again as normal. ICD stands for implantable cardioverter-defibrillator, a device which is designed to protect its carrier from infarction.

All these sophisticated electronics nevertheless do not help in the battle against fear or anxiety in the mind of the wearer. He or she is not only tormented by the concern of an impending heart attack, but also by fears of a surge, which often comes quite unexpectedly, on average twice a year. And it’s not always out-of-time heartbeat which is to blame for the powerful ICD-pulse, but it’s also sometimes due to a false alarm. The more often the involved electrodes discharge, the more uncertain the patient feels. Can I still drive? What about sport? Can an electric field in my immediate vicinity set off my ICD?

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Grabbing the power socket

The first implantable defibrillators were introduced to the marketplace in 1985. Unlike pharmacological therapies, they had no side effects or intolerance problems. Many studies have now shown a decline in mortality as well as preventative capacities for both coronary heart disease and cardiovascular arrest as a result of ventricular tachycardia or ventricular fibrillation. In Germany there are approximately 40,000 ICD-carriers, throughout the world hundreds of thousands. Many devices now also combine defibrillator and pacemaker functions for those with cardiac problems at an advanced stage. Nevertheless, this technology is not cheap: about $US 35,000 is the cost of such a ICD-CRT (Cardiac Resynchronisation Therapy) device.

However, defective electrodes and cables, or an oversensitive sensor, are responsible for power surges which have occurred unnecessarily. Patients report the experience as somewhat like gripping a household power socket or an electric fence. While about four-fifths of those receiving them cope well with the device, the rest struggle with the process of getting used to the new situation. Particularly at risk are those who have had to put up with five or more shocks a year. Depression and anxiety disorders are the most common symptoms of such ordeals. Sometimes genuine psychosis even works it way in.

ICD strikes the soul

There isn’t always just a fear of this strike within the body. Some patients give accounts of feelings of helplessness and of internal foreign control via the machine in their chest. This uncertainty also has an impact on everyday life. The sufferers withdraw and limit their social contacts. At the last annual meeting of the American Heart Association, a lecture reported of restricted sex lives, especially with young ICD-carriers. Finally, it is not only those with heart ailments but also their families and those nearest to them who carry fear of electric shock taking place inside the partner or family member. To some extent, the fear or anxiety is even greater than that of the patients themselves, according to an American study from 2007.

With respect to technical matters, the producers are undertaking a major effort to put a halt on the number of false alarms as much as possible. This includes remote-control testing of the device (DocCheck reported) as well. The physician should – simply on account of there being, due to these psychological disorders, a higher mortality rate compared to mentally more stable cardiac patients – also take a look at the emotional state of the patient in parallel to the implantation itself. In Germany, the Kerckhoff-Klinik in Bad Nauheim for example dedicates itself especially to the mental care of these patients.

Jochen Jordan has for this reason developed a guideline. Patients who have experienced more than five shocks in twelve months, or more than three shocks in the same episode, should as a result be checked for post-traumatic disorder. The treatment options include daily intensive psychotherapy, as well as gathering exact information on the functioning of the ICD, which is supposed to be more life-saver than ticking time bomb. Antidepressants, active relaxation and conversation in self-help groups are also part of the repertoire of the psychology-based cardiologist.

Fewer car accidents than normal

In a small study, Jordan examined 21 patients with PTSD who had experienced up to 70 shocks in one episode. The psychotherapy helped thirteen of them to be cured of the stress syndrome, fifteen patients were very satisfied with the measures. Whoever views the small device on the heart not as a burden but as an insurance against cardiac death can in many cases live almost without restrictions. The car accident rate for ICD-carriers as secondary prevention is 3.4 percent per patient per year and therefore even lower than in the general population. Those involved in sports need not be afraid of a higher rate of false alarms. As Matthias Wilhelm of the University Hospital in Bern states, a reasonable level of stress load even leads to a significantly improved cardiac function. The regular exercise also helps fight depression and allows the patient to sleep peacefully.

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Medicine, Psychiatry, Surgery

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