“This job is killing me” is not a statement of jest. It is a desperate plea of outright sincerity.

Stress, anxiety, depression – all have been associated with an increased risk of cardiovascular disease and mortality. But can interventions to help people cope with stress positively affect longevity and decrease risk of dying? The results of a new study in the Archives of Internal Medicine would imply the answer is an encouraging “yes.”

Constructively dealing with stress is easier said than done, but it would seem logical that if we can reduce our psychological and social stressors we might live longer and delay the inevitable wear and tear on our vessels. This study proved that one such intervention, cognitive behavioral therapy (CBT) for patients who suffered a first heart attack, lowered the risk of fatal and nonfatal recurrent cardiovascular disease events by 41% over eight years.  Nonfatal heart attacks were almost cut in half. Excitement may be dampened by the fact that all-cause mortality did not statistically differ between the intervention and control groups, but did trend towards an improvement in the eight years of follow up.

Definitely less suffering.  Maybe less deaths.

The authors state that psychosocial stressors have been shown to account for an astounding 30% of the attributable risk of having a heart attack. Chronic stressors include low socioeconomic status, low social support, marital problems, and work distress. Emotional factors also correlated with cardiovascular disease include major depression, hostility, anger, and anxiety.

An experienced and specifically trained psychologist usually directs cognitive behavioral therapy for patients. It has been proven to help conditions ranging from social anxiety to borderline personality disorder. While such therapy is by definition supervised and directed by a professional, perhaps we can benefit from a crude understanding of its methods.

In this study, the CBT focused on 5 key components – education, self-monitoring, skills training, cognitive restructuring, and spiritual development. It emphasized stress management, coping with stress, and reducing the experience of daily stress, time urgency, and hostility. The program was highly structured, performed over 20 two-hour sessions during the course of a year.

Education – the goal was for participants to learn more about cardiovascular disease, specifically about anatomy, physiology, symptoms, consequences, the relationship between stress and heart disease, and the symptoms and signs of stress.

Self-monitoring – this goal encompassed becoming more alert to body signals of stress such as heart rate, muscular tension, and pain, with greater attention to behavioral and cognitive clues. This was accomplished in part by the use of diaries to observe, monitor, and reflect upon reactions and behaviors, as well as the use of group processes to enhance observational skills and understanding.

Skills training – this goal was to reduce negative thinking, and to learn to act constructively rather than simply reacting to everyday problems. I’ve heard this method described elsewhere as the imperative to “respond, not react.” A drill book was used for daily behavioral exercises, practicing alternatives to anger, frustration, and depressive reactions. Problem solving and communication skills were rehearsed in the group setting as well.

Cognitive restructuring – this goal involved recognizing negative, hostile, and stress-triggered thoughts and attitudes. Efforts were made to change the participants “internal dialogue” through constructive self-talk, focusing on hostility, worries, and self-defeating attitudes. This component seems to have relied the most on the specialized training of the psychologists to deliver a restructuring of maladaptive thinking styles, again through individual and group efforts

Spiritual development – the goal was to encourage a spiritual reflection upon life, and what is desired for the future. Individual goals, quality of life, and the importance of significant others were discussed. The social and emotional support of the group helped foster self-esteem, optimism, trust and emotional intimacy.

The structure of each session was similar to most CBT programs. This included a weekly specific theme, starting each session with progressive muscular relaxation, followed by reflection and discussion of homework assignments. The current theme was discussed and tied in with previous and new themes, ending with a new homework assignment, often individually tailored. A variety of educational media and materials were used.

Specific skills and themes were tailored to the participants, and the authors noted a predictable (if not clichéd) pattern. Women more often needed focus on self-confidence and self-assertion skills, while men were more often in need of ways to cope with aggressive and hostile behavior.

Another gender difference centered around social networks. Women were often over-involved with social ties, subduing their own self-interests, while men’s social networks tended to provide more unconditional support. (I would also insert another cliché here that men I see in my own practice often suffer from poor tending to social ties, and consequent isolation).

Limitations of this study include the population of patients studied – over 90% were white and of Swedish ancestry, and over 75% were male. There was an overall all-cause decrease in mortality for those attending the CBT program, but this tendency did not meet statistical significance. Prior similar studies have shown conflicting results of stress reduction programs, some concluding that stress management does not affect cardiovascular mortality. However, the authors also reference 2 meta-analyses of health education and stress management programs for patients with coronary artery disease that found a pooled 34% reduction in cardiac mortality and a 29% reduction in recurrent heart attacks.  Meta-analyses are generally considered to be of higher authority than individual trials since the evidence they collect is from multiple independent trials.

So what does this study mean?

Perhaps in a broad sense we can confirm our intuitive sense that stress is harmful to us. A stressful job, aggressive people, a bad relationship, depression, and anxiety all place undue wear and tear not only upon the health of our psyche, but also upon the health of our very substance. More importantly, our hearts and minds can benefit from everyday measures to reduce stress, and to deal constructively and optimistically with the internal and external battles we face.

Participation in a supervised cognitive behavioral therapy group, especially after one suffers a first heart attack, seems like a good idea, and might just prevent or delay a significant burden of recurrent cardiovascular disease.

At the very least, studies like this reaffirm our collective need to step back, to reflect upon the pace and tenor of our strident lives, and to methodically work on a less reactive response to our daily conflicts. It is almost as if an empathic approach to ourselves is needed, one that genuinely considers our woes with some healthy distance, perspective, and practiced coping skills.

Respond, don’t react.

Study Citation:
Randomized Controlled Trial of Cognitive Behavioral Therapy vs. Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients with Coronary Heart Disease: Secondary Prevention in Uppsala Primary Health Care Project (SUPRIM)
Arch Intern Med. 2011; 171(2): 134-140.

A patient reading a copy of Prevention in the waiting room brought to my attention an interesting article entitled “7 Foods That Should Never Cross Your Plate.” I would have to agree that these seven commonly eaten foods should be avoided, so I’ll rehash them here, along with 3 more of my own choosing to flesh out a New Year’s 7 + 3 = Top 10 list.

The lead into the article implores the reader to recognize that “Clean eating means choosing fruits, vegetables, and meats that are raised, grown, and sold with minimal processing.” Michael Pollan, the regarded author of The Omnivores Dilemma and In Defense of Food, puts it even more simply: “Eat food. Not too much. Mostly plants.”

So here are the food items to avoid, in no particular order:

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I just learned (via The New York Times) of a new Google tool that allows the curious person to type in a word or phrase and see how often that term is mentioned in over 5.2 million books over the past 500 years. The Google Ngram tool draws from 500 billion words contained in books published between 1500 and 2008 in English, French, Spanish, German, Chinese and Russian.

If every picture tells a story, then perhaps we can intuit some knowledge from this incredible graphing tool, the analytical powers of which would have been unthinkable only a few years ago. Of course lines on a graph are just data, and exercises in interpretation can be creative, manipulative, dull or brilliant.  That’s why it could be fun.

Here are a few I came up with:

This week the Congressional passage of a bill to extend Bush-era tax cuts was big news. Obama’s health care legislation passed earlier this year remains in limbo as judicial challenges and a Republican Senate gear up to attack. How do the terms “tax cuts, medicare, and medicaid” stack up in terms of their prevalence in our written discourse over the last 100 years?

Does the hive conscience since the 1960’s have a greater appetite for money in one’s own pocket than concerns about health welfare?
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I’m diligently writing a detailed note in the patient’s chart as he speaks of his multiple concerns – severe depression, headaches, and dizziness. I’m not making good eye contact. Often this is effective because I can resist the allure of passively following his narrative to its own diagnostic suspicions. Instead, I can record his intuitive guesses without persuasion, formulating my own independent ideas even as I value his. Except that as I write in his chart I notice streaks of red blood appearing among the black script. Am I hallucinating? Am I capable of making paper bleed? Am I, the doctor, bleeding?

With closer inspection I notice three small cuts on my chapped knuckles and fingers, products of the incessant and obsessive hand washing compelled by modern medicine. We are obliged to wash our hands before and after each patient contact, which leads to about 60 hand washings per day. In the dry winter air this can become punishing to the integrity of the skin barrier.

I apologize to the patient for marring his chart, yet it almost seems symbolic – physician blood spilled upon a script of human affliction. I know I should tear the page out of his chart and write a clean new one, yet the scrawls of black ink and stripes of red blood look like art. It is a poem, punctuated with living iron and crimson flourish. Despite having made poor eye contact in an attempt to distance and strengthen my consideration of his symptoms, ironically I see the commonality of our bleeding.

When the Republicans took back the House of Representatives this past week, John Boehner, the presumptive new Speaker and current Senator from Ohio, unleashed a “sob heard round the world.” As The New York Times quotes:

“I’ve spent my whole life chasing the American dream,” (Boehner) said, beginning to cry. He swallowed and tried again. But describing all the bad jobs he had once led to near sobbing when he got to the line, “I poured my heart and soul into running a small business.”

Boehner has cried in public many other times, the recent election night being only the largest stage to date. The tears also flow at his annual golf tournament, or while watching a child pledge allegiance to the flag, listening to a Republican colleague speak about his Vietnam War experiences, the unveiling of a statue of Ronald Reagan, while accepting various awards, during a rendition of America the Beautiful… Could these tears be signs of major depression? Should melancholy be a disqualification for leadership? Were Clinton’s tears any better?
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I’m increasingly unable to watch the sport of football.  It has become a violent, malicious, hurtful abomination.

Here’s to October baseball instead.

Deadspin videos of concussions this year.

What is in a prenatal vitamin? Why do most doctors recommend them? Is there any evidence taking them is worthwhile? I decided recently that I would read through the ingredients of these vitamins, often touted as “essential vitamins and nutrients, crucial for the healthy development of your baby.” Hmmm. Does that mean eating traces of polyvinyl alcohol every day is beneficial?

The fine print ingredients of such brands as “One A Day”, “Centrum Materna”, “Rite Aid” and even the prescription only “Prenate Elite” are a confusing mess of milligrams, international units, RDA’s, and chemicals. As the makers of Centrum explain, “It is very challenging to formulate vitamins and minerals without the use of non-medicinal ingredients which serve to keep the product stable and to prevent the various ingredients from interacting.” They also find fault in the limited number of suppliers of the active ingredients in prenatal vitamins, and therefore claim substances like gelatin are difficult to avoid.

Let’s take a tour of the prenatal vitamin ingredient zoo.  Among the chemicals found in the most widely available prenatal vitamins are:
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