Mao Jialiang Renji Hospital, Shanghai Jiaotong University School of Medicine
Abstract Cardiac pacemakers are an effective treatment for severe arrhythmias, but due to the severity of the disease itself and the invasive nature of this treatment, they can cause various psychological problems or psychological disorders in some patients. This article presents and discusses the current state of research and coping strategies in this area.
Introduction Cardiac pacemaker implantation is currently the only effective treatment for slow arrhythmias, and the development of in vivo defibrillators and biventricular resynchronization pacemakers based on this approach has also shown good results in the treatment of malignant ventricular arrhythmias and heart failure. However, as an invasive treatment, no matter before or after surgery, due to the difference in patients’ awareness of this treatment may produce adverse emotional reactions, which may seriously lead to psychological disorders and affect the regression of pacemaker efficacy. Correctly identifying and dealing with psychological problems or disorders before and after pacemaker surgery is of positive significance to prevent psychological disorders in pacemaker implantation patients and improve the therapeutic effect. Mao Jialiang, Department of Cardiology, Shanghai Renji Hospital
1 Basics of pacemakers
Pacemaker is an implantable electronic device, which is a very mature therapeutic technology combining bioengineering, electronic technology, microcomputer and clinic, and it is currently applied to save the lives of more than one million patients worldwide every year. Pacemaker surgery has a small incision, no pain, no chest opening, safe and reliable. Bradycardia or transient arrest can lead to severe hemodynamic abnormalities that can be life-threatening. For such severe arrhythmias, drug therapy is often ineffective, and pacemaker implantation can provide a positive and satisfactory result. The installation of a pacemaker not only prevents cardiac events (syncope, heart failure, sudden death) but also improves the quality of life of these patients. Cardiac pacing technology has become one of the most representative achievements in biomedical engineering and is one of the most important methods of treatment of cardiovascular diseases.
A pacemaker is the application of artificially generated pulsed electric currents to stimulate the heart in an appropriate manner to cause myocardial excitation, contraction, increase heart rate, obtain effective cardiac output, restore pumping function, and meet the metabolic needs of the body. The artificial pacing system continues to work effectively in the place of the heart when the heart itself becomes dysfunctional in terms of pacing and conduction due to pathology.
Two conditions must be met for successful artificial cardiac pacing: first, the pacemaker system must be intact and capable of generating electrical impulses of sufficient energy to be delivered to a specific part of the heart. The second is the ability of the heart muscle to excite, conduct, and generate sufficient contractile force in response to electrical stimulation.
The artificial cardiac pacing system consists of three parts: the battery, the pulse generator and the electrode leads. The battery provides the energy; the pulse generator receives the cardiac signals and issues the appropriate electrical pulses; and the electrode leads can transmit in both directions to receive the electrical signals generated between the heart and the pulser.
There are two main types of pacing systems: single-chamber (pacing only the atria or ventricles) and dual-chamber (sequential pacing of the atria and ventricles). At present, with the continuous progress of electronic engineering technology, pacemakers not only develop towards light weight, miniaturization and long life, but also add more and more extracorporeal programmable telemetry, parameter monitoring and automation functions, which can automatically select and change the way of sending pulses according to the heart condition, and automatically adapt to the bradycardia under different conditions, so that the pacemaker can work more in line with the physiological state and reduce the follow-up work of doctors. This enables the pacemaker to work more in line with the physiological state and reduces the intensity of the physician’s follow-up work. At the same time, in the last decade, with the in-depth understanding of cardiac diseases and the development of pacing technology, pacemaker therapy is not only limited to patients with slow arrhythmias in the past, but its scope of treatment has been further expanded, such as three-chamber pacemaker resynchronization for dilated myocardial congestive heart failure and buried automatic defibrillators for malignant ventricular tachyarrhythmias, which are becoming standard treatments with evidence-based medicine. These treatments are becoming one of the standard cardiac therapies with the research of evidence-based medicine.
2 Current status of psychological barriers to pacemaker surgery
What is a psychological disorder? People’s various emotional reactions such as transient tension, anxiety, momentary depression or annoyance that occur for various reasons in daily life are adaptive stresses to the environment that do not yet have a significant impact on their school, work, or family life, and social functioning is well maintained. There are no clinically significant physical symptoms and no identifiable syndromes, which are “normal” people with mental health problems. These psychological problems and emotional reactions can be self-regulated through self-awareness or can be relieved through general conversation.
Psychological disorders are when various factors make the stress become excessively strong and persistent, people’s tension, anxiety, fear and depression and other adverse emotional reactions to a certain degree of severity, lasting a certain period of time, causing a variety of physical symptoms, these clinical syndromes can significantly affect or damage the patient’s health and social function, and this adverse emotional disorders can not be self-relieved, and the patient alone usually can not These clinical symptoms can significantly affect or impair the patient’s health and social functioning. There are clinical syndromes that can be identified, such as anxiety disorders, depressive disorders, somatoform disorders, neuroses, and hypochondria. Patients are capable of reality testing and have an urgent desire to seek medical attention.
Once the pacemaker is placed, it must be carried for life. At this time, the pacemaker becomes an important tool to guarantee their life safety and a source of stress, and if the patient does not have correct and timely knowledge about the pacemaker, or on the contrary, has incorrect understanding of the pacemaker, it will cause psychological problems or even psychological disorders in the patient. The current incidence of psychological disorders in the community population in China is about 4%, and the long-term incidence of psychological disorders in pacemaker patients is about 10%-20%, which is much higher than the incidence of psychological disorders in the general population. The manifestations are mainly anxiety and depression and hypochondria, and its occurrence is related to the patient’s physical, mental and environmental factors. Those who are afraid of disease and/or surgery and anxious before surgery have a high incidence and relatively more severe symptoms after surgery, and it is also related to preoperative psychological interventions. Although the pacemaker helps to eliminate the symptoms caused by the patient’s original bradycardia, if the patient develops a psychological disorder, a new variety of other uncomfortable symptoms may arise, affecting the pacemaker’s regression and the patient’s quality of life. It is important not to think that the pacemaker saves life, but to take the psychological disorders that occur afterwards lightly because they do not directly lead to the patient’s death. At the same time, patients often have doubts about the procedure because they feel that they are not in the desired state of health, causing conflicts between doctors and patients. At present, the psychological disorders of pacemaker patients are often underestimated due to the limited knowledge of non-psychiatrists, and therefore, the psychological disorders of pacemaker patients are often underestimated in clinical practice, resulting in the underdiagnosis and misdiagnosis. The psychological disorders caused by surgery are mainly manifested as anxiety and depression. Patients with cardiac pacemakers have obvious psychological problems such as anxiety, somatization, terror, depression, and interpersonal relationships, and the anxiety and depression of patients can be significantly alleviated by psychological intervention.
3 Psychological problems and barriers before and after surgery
Patients are afraid of the risks and complications after the surgery due to the pain of the disease and the lack of understanding of pacemaker therapy, and they also have to bear a large economic pressure, which makes patients show hesitation, fear, anxiety, irritability, insomnia and uncooperative symptoms before the surgery. The survey shows that before pacemaker surgery, 72.6% of patients do not know about pacemaker implantation, 81.7% of patients are worried about complications during surgery, 60.9% of patients are worried about loss of work capacity after surgery, and 65.8% of patients are worried about increasing the economic burden of their families. These psychological factors can cause negative emotions in patients and are an important reason for patients to refuse surgery or increase problems such as pain during surgery. After the surgery, 30-61% of the patients had symptoms that were not present before the pacemaker implantation and all of them thought that they were related to the pacemaker. 28.6% of the patients were asked why they suspected that the surgery was not done properly, 17.8% of the patients thought that the pacemaker was not working properly, 49.5% of the patients were often worried about the quality of the pacemaker, 12.7% of the patients were worried that the pacemaker was not enough for disease development Patients with pacemaker implantation with postoperative psychological disorders often suffer from a chronic over-concern about the pacemaker, have high expectations, believe that the pacemaker will help them solve all their problems, and blame the pacemaker for any other clinical discomfort or disease. These preoperative and postoperative psychological problems, if not addressed in a timely manner, are important causes of psychological disorders in patients. Recent studies of psychological disorders after surgery have shown that up to 35-42.7% of patients have anxiety and 38.7-39.9% have depression, which is closely related to the variety of somatic symptoms that occur after pacemaker insertion.
4 Psychological disorders after ICD placement
Automatic cardioverter-defibrillators (ICDs) can terminate fatal ventricular tachycardia and ventricular fibrillation in patients, although ICD implantation can significantly improve survival and quality of life for patients. However, the increased awareness of the dangers of the disease, the fear of death again, and the severe discomfort during discharge defibrillation, the constant fear of seizures, and the high financial burden after implantation make ICD implantation patients accompanied by inevitable mental stress, and it is more likely to produce depressive and anxiety disorders than conventional pacemakers. Studies have shown that up to one-half of ICD implantation patients experience significant depression and anxiety due to the above mentioned reasons, and the effects of such negative emotions can last for more than one year in 40%-63% of patients, and patients cannot relieve such nervous and worried emotions by themselves, and such negative emotions can seriously lead to psychological disorders not only causing various physical discomfort symptoms in patients, but also increasing patients’ original malignant arrhythmias occur, affecting the prognosis and quality of life of patients with clinical significance. Therefore, it is important to evaluate early anxiety and depression in patients undergoing automatic cardioverter-defibrillator (ICD) implantation, whose psychological problems need to receive special attention and treatment.
5 Cardiac pacemaker syndrome and psychological disorders
Cardiovascular and neurological symptoms and signs resulting from hemodynamic irregularities due to ventricular pacing or atrioventricular contraction after pacemaker implantation were first reported by Mitsui et al. in 1969 in a patient with a VVI pacemaker who had significant discomfort during ventricular pacing, manifested by dizziness, chest pain, shortness of breath, facial flushing, and cold sweats. This condition was called pacemaker syndrome. At that time, the authors believed that these symptoms were caused by an abnormal pacing frequency, but did not know that they were related to the pacing mode. It has since been gradually recognized that it is caused by atrial asynchronous hemodynamic irregularities during ventricular pacing. The incidence of pacemaker syndrome varies from 5% to 7%, and the subclinical form, in which only blood pressure is reduced without clinical symptoms, can reach 20%. Recent studies using the Symptom Self-Rating Scale (SCL-90), as well as the Depression Self-Rating Scale (SDS) and the Anxiety Self-Rating Scale (SAS), have shown that pacemaker syndrome is highly correlated with psychological disorders, and that many of their clinical symptoms overlap with each other, such as dizziness, fatigue, chest tightness, palpitations, dyspnea, choking, and apprehension and stress. The current biopsychosocial model suggests that the clinical essence of many pacemaker syndromes may be psychological disorders, but due to the influence of the biological model, the incidence of pacemaker syndromes is overestimated and psychological disorders are underestimated by cardiovascular physicians, so that post-pacemaker anxiety and depressive symptoms are often overlooked and easily misdiagnosed as “pacemaker syndrome. As a result, post-pacemaker anxiety and depression are often overlooked and easily misdiagnosed as “pacemaker syndrome” and treatment is delayed. Therefore, in some patients with pacemaker syndrome, clinical symptoms are not well relieved after adjusting pacemaker parameters, while clinical symptoms are often well relieved after psychotherapy.
6 Performance and diagnosis of psychological disorders in pacemaker patients
Anxiety and depression are the main manifestations, and the diagnosis and treatment of anxiety is very challenging in general hospitals. Because anxiety is very common, it is a depressing experience of inner tension and anxiety, worry and foreboding when people face difficulties, or feel an unfavorable situation coming and find it difficult to cope. A normal state of anxiety improves people’s ability to cope with difficulties, and it is often understandable, moderate and relatively short-lived for some reason. Morbid anxiety, on the other hand, is a state in which the cause of the anxiety is not clear, or the cause of the anxiety is disproportionate to the response; the degree of tension and depression caused is beyond what can be tolerated; and the state is not a transient adaptive response, but a persistent one; the more important manifestation of morbid anxiety is that its anxiety and behavior cause significant physical discomfort and affect the patient’s ability to cope with daily life, such as avoidance and withdrawal. The more important manifestation of pathological anxiety is that the anxiety and behavior cause significant physical discomfort and affect coping in daily life, such as avoidance and withdrawal.
Anxiety is a chronic psychological disorder that is associated with cardiovascular symptoms such as chest tightness and palpitations in 60% of cases. These patients are often overly concerned about their own health, sensitive to subtle changes in the body, and often make bad or even disastrous explanations based on their own half-understood medical knowledge, resulting in restlessness, or restlessness, and anxiety. The clinical manifestations are: (l) psychological symptoms: easy to worry, nervousness, anxiety, irritability, fear, ominous foreboding and other anxiety-based emotions, may be accompanied by increased alertness, easily frightened, allergic to sound, inability to concentrate, memory loss, etc. (2) Physical symptoms: easy sweating, dizziness and headache, increased or unstable blood pressure, palpitations, chest tightness and pain, difficulty in breathing, abdominal distension, dyspepsia or diarrhea, frequent urination or difficulty in urination, sexual dysfunction, muscle pain in the neck and back due to tension, and weakness. (3) Motor symptoms: The hands often tremble, and in severe cases, there may be an increase in small movements, or the inability to sit still and agitation.
Depression is a state of mind characterized by a low mood and a loss of interest or pleasure in activities that are usually enjoyable. Depression is a common and normal experience, but if the severity of depression increases, lasts longer, and is accompanied by some other characteristic symptoms (such as sleep disturbance, fatigue, loss of appetite), then it becomes a depressive disorder.
The term “depression” covers many conditions. It can be used to describe a state of mind, a symptom, a group of syndromes or a disease entity. Here we refer to depressive disorders as a group of syndromes or as a disease entity. Depending on the severity and duration of the onset, there are several types, ranging from insidious depression, which is sullen, to severe depression, which is grief-stricken and even occurs in a state of malaise. Just as in cardiovascular medicine, “viral myocarditis” has a wide range of different episodes. The usual criteria for symptoms are: depressed mood as the main feature and lasting at least 2 weeks, during which at least four of the following symptoms are present: (1) loss of interest in daily activities, no sense of pleasure; (2) significant loss of energy, persistent fatigue without cause; (3) psychomotor retardation or agitation; (4) low self-esteem, or self-blame, or feelings of guilt, which may reach the level of delusions; (5) (5), difficulty in association, or a significant decrease in the ability to think and concentrate; (6), feeling that life is meaningless, recurrent thoughts of death, or suicidal behavior; (7), insomnia, or early awakening, or excessive sleep; (8), loss of appetite, or significant weight loss; (9), a significant decrease in sexual desire; (10), feeling a bleak future; (11), a sense of worthlessness and guilt.
The above depression is a moderate to severe clinical manifestation, in which we see the depressive disorder usually to a lesser degree, mainly in the form of depressive neurosis, the symptom criteria are: persistent depressed mood as the main clinical phase; accompanied by at least three or more of the following symptoms.
(1), diminished interest but not complete loss of interest; (2), loss of confidence in the future but not pessimism and despair; (3), fatigue and weakness or lack of energy; (4), decreased self-evaluation but willingness to receive encouragement and praise; (5), reluctance to initiate contact with people but good passive contact and willingness to receive sympathy and support; (6), thoughts of death but heavy concern; (7), self-perceived seriousness of the illness but actively seeking treatment. This disorder is a kind of neurological disorder with depressed mood as the main clinical phase and a prolonged course. It is often accompanied by anxiety, somatic discomfort and sleep disturbances. Depression is usually mild, but because it is prolonged, the patient feels distressed and often seeks treatment without significant impact on daily life.
There is also a diagnosis of depressive disorder called occult depressive disorder, also known as depressive equipoise, which is an atypical category of depression. It is an atypical type of depression. The substance of the disorder is depression, but the surface is a somatic disorder. The main clinical manifestations include recurrent and persistent somatic and vegetative symptoms, such as headache, insomnia, dizziness, anorexia, palpitations, chest tightness, shortness of breath, upper abdominal discomfort, numbness of the extremities, generalized weakness and pain, suppression of sexual desire, weight loss, and sleep disturbance. The emotional symptoms of depression are often masked by the physical symptoms and are not obvious, and patients often attribute their discomfort to cardiac or other diseases, and they often turn to cardiovascular medicine or other specialties instead of psychiatrists. Patients complain prominently of somatic symptoms of depression and often deny having depressive mood. The somatic symptoms are multi-systemic and sometimes cannot be expressed in a specific and precise manner, but only vaguely described as discomfort, or they may see a cardiologist for chest tightness, a neurologist for headache, or a gastroenterologist for indigestion. However, when these patients are investigated in depth, they can still be found to have depressive symptoms such as poor mood, loss of cheerfulness, negative perceptions, worrying, and loss of interest in past hobbies. Pre-existing suspicions, such as fear of coronary heart disease, myocardial infarction or heart failure, are also often found.
The diagnosis of psychological disorders in pacemaker patients can be based on the following considerations.
1. cognitive aspects: excessive attention to the working status of the pacemaker, hypersensitivity to some minor symptoms of the patient, suspicion of pacemaker malfunction at the first sign of discomfort.
2. Personality basis: easily sensitive, suspicious, thoughtful, and often unable to put things down.
3. psycho-emotional aspects: easy to worry and fear, nervousness and anxiety, irritability and agitation; or depressed, depression, severe cases may have a sense of uselessness and hopelessness, self-evaluation is too low, etc.
4. behavioral aspects: sleep disorders are more prominent, including insomnia, early awakening, excessive dreaming; loss of energy, fatigue without obvious reasons; easily frightened, fear of noise, allergic to sound; in severe cases, lack of interest in people and things, want to cry or cry easily.
5. Intellectual: slow thinking, memory loss; inability to concentrate, unclear narrative expression.
6. Somatic symptoms.
1) Firstly, the cardiovascular system manifests: chest discomfort, non-cardiac chest pain, feeling of obstruction in the throat, paroxysmal palpitations, rapid heartbeat, unstable blood pressure, easy to fluctuate up and down, etc.
(2) Secondly, it may be accompanied by other multi-system symptoms: (1) Phytomuscular sensory system: headache and dizziness, muscle discomfort or pain, tingling of limbs, trembling of hands, easy sweating, blurred vision. (2) Genitourinary system: frequent urination, decreased sex drive. (3) Respiratory system: choking sensation, like to sigh loudly. (4) Digestive system: loss of appetite, no hunger, dry mouth, constipation, easy bloating and indigestion, weight loss may occur.
8. The clinical symptoms caused by the laboratory tests are found to be inconsistent with the actual test results.
In the diagnosis, the above clinical manifestations can occur in combination. The absence of depressive and anxiety complaints does not exclude the presence of a psychological disorder. It should be noted that, as with most patients with psychological disorders who present to general hospitals, pacemaker implantation patients they have a preconception of cardiovascular disease and they often refuse to admit or discuss the problem of psychological disorders with their physicians. Therefore, when understanding the patient’s condition, it is important not to ask straightforwardly how the patient is feeling, which can cause misunderstanding and resistance, but rather to understand the condition in terms of the patient’s behavior and other multisystem symptoms, which is different from the way counseling clinics ask about diagnosing psychological disorders. In addition, the diagnosis of psychological disorders still requires caution, and in the present situation as a non-psychiatrist, it is appropriate to diagnose such patients in terms of anxiety-depressive states, while still paying great attention to the pacemaker itself or to problems brought on by other diseases, to make a correct estimation and diagnosis of the condition.
7 Prevention and treatment of pacemaker psychological disorders
The causes of preoperative anxiety and depression in pacemaker patients may be multifaceted, so psychotherapy should be one of the supplementary treatment measures for pacemaker patients before and after surgery.
The surgeon should explain the etiology, development and healing of the disease with patience and enthusiasm and clear language before surgery according to the psychological reaction characteristics of pacemaker implantation patients, combined with his clinical experience, and give appropriate explanations to them. Talk to patients and their relatives so that they can understand the meaning and methods of pacemaker: (1) patiently explain the necessity of pacemaker installation and objectively introduce what help and problems the procedure can bring to patients. Be realistic and do not exaggerate, otherwise the patient will be misled to believe that the pacemaker can solve “all the problems” of heart disease, and will become psychologically unbalanced when there is no “miracle” of treatment that the patient thinks may occur after the operation. (2) Understand the patient’s opinion about the pacemaker and explain the basic steps of the operation and the operation in order to eliminate the patient’s worries. The patient should be instructed to relax and be introduced to patients who have pacemakers in the same ward to communicate with them to relieve their worries and tension. (3) Tell the patient about the discomfort during the operation, how to cooperate and precautions. All operations are performed under fluoroscopy, and the safety of the operation is high, and accidents during the operation are extremely rare. (4) After implanting the pacemaker, tell the patient that the quality of the pacemaker is becoming more and more perfect and the probability of malfunction is extremely low. (5) Encourage the patient to work and live like a normal person, and in addition to this, actively participate in less strenuous activities, such as traveling, bicycling, dancing, running and swimming. (6) Provide psychological guidance and psychotherapy to patients with depression, anxiety, fear and other psychological conditions, and give medication if necessary. (7) Establish a complete patient file and psychological support system and a sound follow-up system. These communication and measures are important to promote the rapid and comprehensive recovery of patients with pacemakers, avoid the occurrence of post-surgical psychological disorders and improve the quality of survival in the future.
Anxiety and depressive symptoms can be treated with medication, psychotherapy, behavioral therapy such as systematic relaxation and anxiety control training, as well as cognitive and other therapies, with good results in most patients.
Pharmacological treatment.
1. Anti-anxiety tension and sedative-hypnotic drugs
Benzodiazepines (BDZ) are the main drugs. Smaller doses play an anti-anxiety and tension role, while larger doses play a sedative-hypnotic role. Anti-anxiety and nervousness commonly used are: eszopiclone (Scholastin), 1~2 mg/dose, 2~3 times a day orally; alprazolam (Jiajing Valium), 0.2~0.8 mg/dose, 2~3 times a day orally; diazepam (Valium), 2.5~10 mg/dose, 2~4 times a day orally; non-benzodiazepine anti-anxiety drugs, buspirone, 5~10 mg/dose, 3 times a day orally Phenobarbital (luminal), 15~30 mg/dose, 2~3 times a day orally. Commonly used for sedation and hypnosis are: triazolam (Hailsham), 0.25~0.5 mg, eszopiclone, 1~2 mg, taken orally at bedtime; clonidine (clonidine), 1-2 mg, taken orally at bedtime; midazolam (quick sleep), 7.5~15 mg, taken orally at bedtime; zopiclone (Yimengzhi), 7.5 mg, taken orally at bedtime.
2. Antidepressants
The principle of antidepressant treatment: the diagnosis is clear, the patient’s symptom characteristics are fully considered, and the medication is individualized and rational; the dose is gradually increased, and the smallest effective dose is used to minimize adverse reactions and improve compliance; if the small dose is not effective, the dose is increased to the full dose (the upper limit of the effective drug) and a long enough course of treatment (>4-6 weeks) according to the adverse reactions and tolerance; if it is not effective, a change of medication can be considered (another drug of the same type or another drug with a different mechanism of action). Another drug or another drug with a different mechanism of action). As far as possible, a single drug should be used in sufficient quantity and for a full course of treatment. Combination of two or more antidepressants is generally not recommended.
It must be noted that, in addition to explaining the patient’s condition before treatment, we should also explain to the patient and his family the nature of the drug, its effects and possible adverse reactions and countermeasures before using the drug, because the patient does not want to be given this kind of treatment drugs, so we should explain to them in order to obtain their understanding, and strive for their active cooperation, so that they can take the drug on time and in the right amount as instructed, and closely observe the condition and adverse reactions during treatment, During the treatment period, we should closely observe the condition and adverse effects, and deal with them in time.
Depression is often a chronic, relapse-prone disease, and it has a concept of the whole course of treatment: that is, it can be divided into acute treatment, consolidation treatment and maintenance treatment.
1.Acute treatment: The goal of acute treatment is to control symptoms and achieve clinical cure as much as possible. Drug treatment generally starts to take effect in 1~2 weeks, and the efficiency of treatment is linearly related to time. If the patient does not work for 6-8 weeks with drug treatment, it may be effective to switch to other drugs with different mechanisms of action.
2, consolidation period treatment: after the acute treatment, the patient’s symptoms have been basically relieved, social function gradually restored, at this time should not immediately reduce the drug, due to maintain the larger drug dose, consolidation treatment for a period of time, supplemented by the corresponding psychotherapy. From the complete remission of symptoms, should continue to consolidate treatment for 4-8 months.
3, maintenance treatment: the goal of maintenance treatment is to prevent relapse. After the acute and maintenance treatment, the patient’s symptoms are controlled, social function is further restored, and he/she is aware of the disease and the need for treatment.
TCAs also block other receptors such as histamine receptors and toxopamine receptors, and side effects are caused by blocking other receptors (dizziness, weakness, drowsiness, dry mouth, constipation, etc.). etc.). Since high doses of TCAs can have significant arrhythmic side effects on the heart, caution is needed when using TCAs in cardiovascular medicine, but small doses are still safe. Doxepin is commonly used, starting at 12.5 mg/dose twice daily and gradually increasing to 50-75 mg daily. onset of action is 1 to 2 weeks.
5-Hydroxytryptamine reuptake inhibitors (SSRIs) are a new class of antidepressants developed in recent years, with the main pharmacological effect of selectively inhibiting 5-HT reuptake and increasing the synaptic gap 5-HT content for therapeutic purposes. Clinical use characteristics: anticholinergic adverse reactions, cardiovascular and liver, kidney function, light sedative effect, good patient tolerance, high compliance, easy to take, especially in cardiovascular medicine can be used safely. Because of the small sedative effect, it can be taken mostly during the day, and can be taken at night if there is sleepiness and weakness. Commonly used are fluoxetine, 20 mg/dose, once a day in the morning; paroxetine, 10-20 mg/dose, once a day in the morning; sertraline, 50 mg/dose, once a day in the morning.
The main side effects of 5-hydroxytryptamine reuptake inhibitors are nausea, anorexia, abdominal pain, dry mouth, diarrhea, and dizziness, excessive sweating, nervousness, tremor, anxiety, and sexual dysfunction. 5-hydroxytryptamine reuptake inhibitors have a slow onset of action, usually taking 2-4 weeks to improve the patient’s symptoms. Try to reduce the drug slowly at the end of the course of treatment to avoid withdrawal reactions.
5-Hydroxytryptamine and norepinephrine reuptake inhibitors (S N R I s 〉 venlafaxine (formerly known as venlafaxine) is the only existing SNRI S. The main pharmacological effect is to have NE and norepinephrine reuptake inhibitors. The main pharmacological effect is to have NE and 5-HT dual reuptake inhibition, fast onset of action, in 1 ~ 2 weeks after taking the effect. Dosage: Extended-release capsules of 75 mg or 150 mg once daily.
New antidepressant (NaSSA) with enhanced effects on both NE and 5-HT transmission, Mirtazapine, pharmacological effects: (1) blocking α2-adrenergic receptors, increasing brain NE levels. (2) Blocking 5-HT, enhancing the firing rate, promoting the release of 5-HT, and increasing the level of 5-HT in the brain. (3) Inhibit 5-HT2 and 5-HT3 receptors, thus avoiding the side effects of some antidepressants such as SSRIs.
It has good antidepressant and anxiolytic effects, especially for depression with anxiety and sleep disorders and geriatric depression. Common adverse effects include sedation, drowsiness, dizziness, fatigue, dry mouth, and appetite and weight gain. Dosage: 15-30 mg/dose, taken orally at bedtime each night.
Dextran is a combination of a small dose of the antipsychotic trifloxystrobin and a small dose of the tricyclic antidepressant tetramethyl anthracycline, whose pharmacological effects are the result of the combined action of the two components. The pharmacological effect is the result of the combined action of the two components. The main manifestation is to increase the content of different neurotransmitters such as dopamine, NE and 5-HT in the synaptic gap. The two components have synergistic and side effect antagonistic effects in the therapeutic effect, which can effectively anti-anxiety and antidepressant, and improve somatic symptoms. It has a fast onset of action and few side effects. Dosage: Take 2 tablets daily, one in the morning or one in the morning and one at noon.
Most antidepressants have anxiolytic effects and can be effective in treating mixed depression and anxiety. In addition, it is sometimes difficult for cardiovascular specialists to diagnose whether a pacemaker patient has a psychological disorder, but if there is a suspicion that anxiety-depression is involved in the patient’s symptoms, diagnostic treatment with anti-anxiety-depression drugs can be given.
During the diagnostic treatment, if the patient is found to be severely depressed with suicidal tendencies or difficult to treat, prompt referral to psychiatry is required.
Case 1 Identification and treatment of psychological disorders in patients with cardiac pacemakers
Patient Female 70 years old, retired, but still working and teaching, teaching computer knowledge. She had a pacemaker for nine years, and had a pacemaker replaced for two months due to depletion of the pacemaker’s electrical energy. After the pacemaker was replaced, the patient felt palpitations, chest tightness and gasping for air, and even a feeling of suffocation when the chest tightness was severe. The pacemaker was suspected to be a problem, but the pacemaker program control showed that the pacemaker was in good working condition and had a history of short bursts of tachycardia, so the patient was informed that the pacemaker was working well and was given Betalex oral therapy. Two weeks later, the patient still felt the above mentioned discomfort at the follow-up visit. The patient’s facial expression was tense, and she spoke more and faster during the visit. The doctor considered that these symptoms might be caused by psychiatric factors, but the patient denied it.
When asked about her sleep, she said she was fine, sleeping for four to five hours. However, upon further questioning, the patient reported that she often had nightmares and sometimes woke up from them, such as when the Japs entered the village and she was running away (during the anti-Japanese war, the patient lived in the northeast), or when she slowly fell from the sky and had the fear of falling to her death, she would wake up when she dreamed of being caught by the Japs or falling to the ground, and sometimes she often dreamed that she would always step on the stairs and could not find a place to urinate.
In addition to cardiovascular symptoms such as palpitations and chest tightness, she also has other multi-system symptoms: stomach pain and indigestion, muscle pain in the neck and back, dizziness and headache, numbness and trembling in the hands and feet, sometimes weakness in the legs when walking, discomfort in the throat, easy fatigue and blurred vision.
He is emotionally volatile, thoughtful, easily sad, and can’t help but shed tears when seeing sad episodes on TV (the patient was not like this in the past), easily stressed out in situations, and allergic to sound and afraid of noise.
The patient’s score was 45 on the Zung Psychological Self-Assessment Scale and 32 on the SDS. The patient was considered to have symptoms of anxiety and depression, and was given Benadryl 20mg orally, Doxepin 12.5mg orally at night before bedtime, and Sulpiride 0.5 orally twice daily. Two weeks later, the patient’s symptoms were significantly relieved. One and a half months after treatment, the patient’s symptoms basically disappeared, and the SAS score decreased to 25 and SDS score decreased to 22.
Case 2: Identification and treatment of psychological disorders in a patient with an automatic cardioverter-defibrillator (ICD)
The patient was 67 years old and was placed with an automatic cardioverter-defibrillator (ICD) for “dilated cardiomyopathy with cardiac insufficiency and ventricular tachycardia with shock”. During the six-month follow-up after surgery, the patient had no further episodes of ventricular tachycardia, but he was still worried that his disease would not be seen properly, and he was emotionally ill and easily pessimistic. The patient doubted the need for ICD fitting because of the absence of episodes of ventricular tachycardia. However, 7 months after the surgery, the patient had another attack of ventricular tachycardia and the ICD was successfully resuscitated in time, so the patient could agree on the necessity of ICD installation. It would be a heavy financial burden to replace the ICD.
In the following month, the patient was further depressed and suffered from sleep disturbances, general weakness and dizziness. Ventricular tachycardia episodes and ICD resuscitation became more frequent, up to four times a month. Considering that the patient’s depressed mood might be related to the frequent ventricular tachycardia episodes, the patient was diagnosed as anxious and depressed with a score of 44 on the Zung Psychological Self-Rating Scale (SAS) and 43 on the SDS. The patient was given Bacitracin 20mg orally and Doxepin 12.5mg orally at night before bedtime, along with psychological counseling and comfort. After one month of treatment, the patient’s mood improved significantly, sleep improved, fatigue decreased and ventricular tachycardia stopped. After two months, the patient’s SAS score decreased to 23 and SDS score decreased to 32. The above mentioned conditions did not recur after one year of anti-anxiety and depression treatment, and the patient maintained a good mood.
References
1. Juxian Yang, Yulong Chen, Jialiang Mao, et al, “Psychological disorders in the eyes of internists”, Shanghai Science and Technology Press, 2007.
2. Wu Wenyuan, Ji Jianlin, et al, Mental Health in General Hospitals, Shanghai Science and Technology Literature Press, 2001.
3. Zhu Yan, Du Huifang, Chen Xuemei. Analysis of Psychological Problems of Patients after Artificial Pacemaker Installation. Chinese Journal of Clinical Medical Research,2006,12(15):2049 ．
4. Liu Qiuwu, Li Ping, Xu Munhua, et al. Analysis of psychological conditions and influencing factors of pacemaker carriers. Shanghai Nursing. 2002, 2(2):8
5. Yang, H., Qi, S., Shen, C., et al. Preoperative psychological status of cardiac pacing patients and the role of psychological intervention. Chinese Journal of Cardiac Pacing and Cardiac Electrophysiology. 2003, 17(3): 189.
6. Song Z, He J, Sun GL, et al. Physical and psychological rehabilitation of patients after cardiac pacemaker implantation. Chinese Journal of Cardiac Arrhythmia, 2003, 7(6):382
7. Wang Dongping, Wei Shiqiang, Zhang Sanlin, et al. Investigation and analysis of psychological influences on patients with pacemaker placement. Journal of Practical Medicine. 2006, 23(8):982
8. Wen Shuyin, Deng Xiaojian, Zhou Fangming, et al. Clinical analysis of 39 cases of depression after permanent cardiac pacemaker placement. Journal of Cardiovascular Rehabilitation Medicine. 2005, 14(1):21
9. Huang Y, Fei X, Ren Y Y, et al. Investigation of preoperative anxiety in patients with permanent cardiac pacemaker implantation. Journal of PLA Nursing, 2006, 23(8): 34
10. Chen Yadi, Chen Junzhu , Jiang Qianjin. Mental health status of patients with permanent pacemaker implantation and related factors. Chinese Journal of Mental Health, 2003, l7(6):393