The importance of mental health in overall health and well-being is increasingly recognised. Despite this, the impact of many chronic diseases on mental health is under-recognised and under-treated. Lower extremity peripheral arterial disease (PAD) is a common, chronic disease involving atherosclerosis affecting the arterial system distal to the aortic arch, and is associated with significant morbidity and mortality. The impact of PAD on physical function and quality of life is well documented. There is also a higher prevalence of depression in patients with cardiovascular disease and depression is a major determinant of health status and outcome. Despite this, the impact of PAD on mental health and the psychological impact of limb symptoms are an under-researched area.
Understanding Peripheral Arterial Disease and its Psychological Impact
The peripheral artery disease is a cardiovascular condition, which is built up via atherosclerosis. Atherosclerosis is the progressive development of plaques within the arteries that transport blood to the brain, heart, limbs, and kidneys, however, when the body’s disability becomes visible. PAD is a form of atherosclerosis that affects the arteries serving the legs, arms, and head and increases depending on which stroke, coronary, or cerebral artery diseases manifest. The most common symptoms are intermittent claudication, ischemic rest pain, ulcers, gangrene, and strokes. Intermittent claudication is cramping leg pain that occurs when walking or exercising and is relieved by rest. This is caused by the muscles not receiving the adequate supply of oxygen due to the narrowed arteries; the accumulation of lactic acid induces the cramping pain. The absence of hair or dry shiny skin over the legs and diminished or absence of pedal pulses, usually at the dorsal pedis and posterior tibial, are anticipated signs of PAD, notably the chronic limb ischemia form. This will, in turn, lead to ischemic rest pain, ulcers, gangrene, and strokes, which all signify a grave outlook for the patient. Ischemic rest occurs when blood flow is not sufficient to meet the demands of tissue when the patient is at rest; any activity requiring an increase in oxygen supply, i.e. hair growth and wound healing, will not occur and the tissue is at risk of damage. Ulcers and gangrene form when tissue damage occurs due to lack of blood supply. Critical ischemia with ulceration or gangrene carries a high risk of limb amputation. A stroke will occur when the brain does not receive enough oxygen, normally when emboli from the atherosclerotic plaques in the other arteries dislodge. All of these symptoms are important to understand with regard to the psychological effects of the patient.
Definition and Causes of Peripheral Arterial Disease
Alumni from the University of Tasmania created a random case study of 1125 patients to conduct a study of the mortality rate among PAD. This study began in 1996 with patients from local medical centers in Tasmania and lasted 5 years. A report was administered to the PAD patients, and the mortality rate was compared to that of the general population. This study concluded with 238 reported deaths. The main causes of death were circulatory diseases, and the death rate was 3 times higher than that of the general population. This data is consistent with the Edinburgh Artery study, which also aimed to determine the risk of cardiovascular morbidity and mortality in patients with PAD. This study concluded that the relative risk of all-cause mortality in PAD was 1.9 times higher than the control. These results have heavily demonstrated that PAD is a severe and life-threatening disease, as there is a high risk of cardiovascular events such as strokes and heart attacks. The high cardiovascular mortality rate is also parallel to that of cancer and AIDS.
PAD is caused by arteriosclerosis, where plaque builds up on the walls of the arteries. This is due to high cholesterol and triglyceride levels caused by lipids and fats in the blood. This causes the affected arteries to become narrowed and hardened, resulting in less blood flow to the muscles. Most PAD patients are over 50 years old, and the peak of the disease is between 65-75 years of age.
Arterial disease is a cardiovascular disorder that affects the major large blood vessels, “arteries,” that supply the body with oxygen and nutrients through blood flow. The disease is known in two types. The most common type is Peripheral Arterial Disease (PAD), which affects arteries outside the brain and heart, supplying blood flow to the brain and heart. The second known disease is Central Arterial Disease, which affects the arteries that supply blood to the brain and, less commonly, to the arms. This essay will mainly look at and examine in depth the widely known PAD and its psychological effects on patients.
The Psychological Effects of Peripheral Arterial Disease
The most consistent findings are those related to quality of life. Several studies have shown that patients with PAD have worse quality of life than those with heart disease. This is due in part to the fact that PAD is associated with a decline in physical functioning and increased morbidity and mortality. However, even when controlling for physical function, patients with PAD have a poorer quality of life than those with other cardiac diseases. In one such study, quality of life in PAD patients was compared to age and sex matched controls, as well as patients with coronary artery disease and hypertension. The PAD group scored significantly lower in all areas of quality of life, especially in the physical domain.
The psychological effects of peripheral arterial disease (PAD) have been poorly understood, despite various patient reports. Research in this area has only recently begun, with more evidence suggesting a significant psychological burden associated with PAD. One reason for the lack of research on the psychological effects of PAD is that it has been traditionally viewed as a disease of the aged and those debilitated by other chronic diseases. The primary focus of researchers and clinicians has been on the physiological impairment and functional limitations of patients with PAD. The few studies that have examined the psychological effects of PAD suggest that it may be comparable to or even worse than that experienced by patients with other chronic diseases, particularly heart disease and cancer.
Addressing the Psychological Impact of Peripheral Arterial Disease
Since PAD affects patients’ ability to function as they used to in the community, with an improvement in symptoms seen most in those patients who undergo lower extremity revascularization, lifestyle modification is an important factor in the prevention and treatment of PAD. However, it is difficult for many patients to make alterations without improving their symptoms with invasive therapy. Health status and quality of life are likely to be impaired in patients with PAD. This may be the result of symptoms and functional impairment, concomitant diseases, or the treatment for PAD. It has been shown that the decline in quality of life is greater in patients with intermittent claudication when compared to patients with IHD or stroke. Therefore, there are mental health implications for those with PAD. Considering this large burden on quality of life in PAD, it is interesting to note the lack of attention paid to mental health implications.
Importance of Psychological Support in Peripheral Arterial Disease
Patients suffering from PAD may not express their concerns regarding their mental health but are significantly affected. These psychological effects are difficult to quantify and are often overshadowed by the concern regarding the physical implications of PAD. However, it is essential to acknowledge the impact on mental health caused by peripheral arterial disease and the implications it has on the patient’s well-being. This change in lifestyle is a significant contributing factor in the development of depression. Often, these patients have to give up activities that they once enjoyed due to the pain experienced in the lower limbs after exercise. This creates a sense of loss which can lead to feelings of uselessness and depression. The pain caused by PAD is also a common cause of irritability in patients and can lead to altered self-image and others’ impression of the patient. Anxiety is also a common mental health effect of PAD. In a study, it was concluded that anxiety was more prevalent in PAD patients than in ischemic heart disease patients. They also found that anxiety and depression were significant predictors of cardiac events and mortality in PAD patients. This could be due to anxiety causing increased muscle tension, which would worsen the intermittent claudication, and the depression/altered self-image leading to a lack of effort to improve the condition of the disease. Although it is difficult to confirm, suspected cognitive impairment has also been noted in PAD patients. This range of psychological effects of PAD can greatly hinder the patient’s attempts to improve their condition and can even cause further deterioration.
Strategies for Managing Psychological Impact
Encouragement to engage in physical activity despite symptoms or formal supervised exercise therapy has obvious benefits for mood and self-esteem, albeit that the logistics in achieving this can be difficult. Patients with symptomatic PAD exhibit significantly greater functional impairment and more restricted activity than individuals without leg symptoms. This is a pattern frequently seen in depression, and it has been noted that the level of physical activity is an independent predictor of depression status over 12 months. Measures which aim to enhance social support are often of benefit to mental health. This could be through formal group therapy in which the focus is on psychological well-being, or through informal means such as jointly walking with others who have similar medical problems.
Adequate education about the nature, symptoms, and prognosis of the disease can serve to dispel irrational beliefs, which can be a source of distress. Engagement in health-promoting behaviors is often preceded by a change in health attitudes. Since attitudes are known to be influenced by beliefs and subjective norms, helping patients to form more positive PAD-specific attitudes through correcting misinformation and stressing the benefits of risk factor modification may impact on general psychological well-being.
A number of general strategies for managing the psychological impact can be recommended. Principal amongst these is the effective treatment of the PAD itself. As might be anticipated, pain-free patients (whether assessed subjectively or on the apparently more objective basis of pain-free walking) have been found to exhibit less psychological distress than those who still experience pain. Where the cause of the psychological distress seems more directly related to a sense of physical limitation than to negative mood or specific psychological conditions, attention to revascularization is likely to be beneficial. It is known that self-concept can be influenced by the subjective interpretation of recent performance. Improvement in walking ability is thus a most effective means of raising self-esteem in those who perceive themselves to have a walking impairment.
Given the scale of distress caused in sufferers has not been matched by studies examining the psychological impact of PAD, it is unsurprising that a recent review called for research into this area to be given a high priority.
Role of Healthcare Professionals in Addressing Mental Health
The National Institute for Health and Clinical Excellence report suggests that people with chronic illness are unable to make changes in their lives that can benefit their illness. In line with this, one important factor in patients that requires assessment is their stage of change. This is concerned with a person’s readiness to change their health behaviour. The majority of PAD sufferers are in the contemplation or preparation stage regarding health behaviour change. It is suggested that patients in the precontemplation stage remain in therapy for a psychological issue for an extended period of time before they consider changes. At this point, it is best for the patient’s mental health and their physical health to first address their psychological issue, whether treated or not, before discussing lifestyle changes. This suggests that an assessment of stage of change needs to be ongoing as the patient’s state of readiness may fluctuate with their mental health state. The implications of this are that it will affect the timing of when an appropriate health behaviour change intervention is given. An understanding of the complex interplay between psychological factors and health behaviour can enable healthcare professionals to assist PAD patients in an informed manner. The specific issues in patients can be addressed by healthcare professionals with targeted psychological intervention. Behavioural activation is a concept whereby low mood and depression are seen as a result of reduced positive reinforcement in an individual’s life causing a reduction in enjoyable activities and a downward spiral in mood. This could be relevant to PAD patients due to mobility problems. This intervention aims to increase a patient’s engagement in activities that bring them pleasure or a sense of achievement. A qualitative study of PAD patients suggested that psychological interventions for depression should be moved out of mental health settings and provided in clinic or home-based settings specific to their needs. This would be beneficial as it would reduce burden in those with mobility problems and in the case of behavioural activation could bring support directly to the patient in their own environment.
Conclusion
Psychological morbidity is frequently neglected in patients with chronic diseases; however, the strong association between poor mental health outcomes and increased morbidity and mortality heightens the importance for it to be assessed and managed in an effective manner. This literature review has provided perspectives on what PAD is, an overview of the psychological impact that it has, and has suggested methods of best managing the psychological health of patients with PAD. Chronic diseases compel the patient and their families to undertake many adaptive changes. This process of adapting to changes and managing forces that act to reduce QOL requires a patient-centered approach to care. Although the review provides a comprehensive understanding of the psychological effect of PAD, it is clear that further research is required to develop an effective model of care. The burden of psychological morbidity in PAD is a serious issue that needs to be addressed if we are to improve the quality of care delivered to our patients. With increasing awareness and understanding of the far-reaching consequences that PAD has on the mental health of affected individuals, more can be done to prevent or manage these conditions. Future research in developing cost-effective treatment strategies for psychological co-morbidities in PAD will contribute to the improvement in the overall quality of life of affected individuals. With an improved quality of life for sufferers, there is potential that the progression of PAD may be positively influenced. This review has raised awareness of the psychological impact of PAD, and with future research and implementation of care, it is possible that the burden of psychological co-morbidity will be greatly reduced.
