he implantable cardioverter-defibrillator (ICD) has revolutionized the care of patients at risk for life-threatening arrhythmias. Large-scale clinical trials established mortality benefits for the ICD over usual care or medications 1,2 and led to wider use for both primary and secondary prevention indications. More recent research confirms that the mortality benefits of the ICD extend over 8-year follow-up when compared with usual care. 3 These clinical trial successes, in terms of mortality, have allowed for greater focus on patientcentered outcomes, such as quality of life, device acceptance, psychological well-being, and trauma reactions in research and clinical care. 4 Shock has been a primary focus in this work because of its potentially traumatic impact on the patient experience. Although there is mixed evidence on the effect of single ICD shocks, 5,6 the literature consistently supports the negative impact of Ͼ5 shocks on quality of life and emotional distress. 7,8 ICD shock has been a focus of research interest because it is a unique experience for the ICD patient and can be perceived as a traumatic event. In addition, the existence of concomitant heart disease, angina, congestive heart failure, or previous sudden death may create sensitivity to traumatic stress that warrants improved understanding by attending electrophysiologists. Although psychological distress in ICD patients has been explored, the possibility that some ICD patients have trauma reactions, up to and including posttraumatic stress disorder (PTSD), has garnered increased attention recently. Therefore, the purposes of this report are to highlight the theory and research addressing psychological distress including PTSD in electrophysiology clinics, to discuss clinical management of these sequelae, and to suggest areas of future research and development. Psychosocial Distress of ICD Patients in Electrophysiology ClinicsPrevention and identification of distress in ICD patients represents comprehensive, high-quality care, regardless of the cause (eg, depression, anxiety, trauma), consistent with the biopsychosocial model of care. 9 This model of care entails the conceptualization and treatment of health problems as an interplay between biological factors, psychological factors, and social factors culminating in the manifestation of symptoms. For an electrophysiologist, these ambitious goals can include prevention of distress through cardiac care and education, recognition of distress warranting referral, optimizing quality-of-life (QoL) outcomes, and promoting patient acceptance of the ICD. Clearly, these are not easily accomplished without sufficient awareness, clinical support, and interdisciplinary expertise. Below are some key considerations for daily clinical practice. Prevalence and Impact of Psychosocial DistressGeneral or ICD-specific anxiety as a psychological morbidity has a point prevalence of 13% to 38% of ICD recipients in cross-sectional research. 4 Longitudinal assessment of anxiety has indicated that approximately 35% of pati...

OBJECTIVEThis study evaluated the effect of cognitive behavioral therapy (CBT) plus lifestyle counseling in primary care on hemoglobin A 1c (HbA 1c ) in rural adult patients with type 2 diabetes (T2D) and comorbid depressive or regimen-related distress (RRD) symptoms. RESEARCH DESIGN AND METHODSThis study was a randomized controlled trial of a 16-session severity-tailored CBT plus lifestyle counseling intervention compared with usual care. Outcomes included changes in HbA 1c , RRD, depressive symptoms, self-care behaviors, and medication adherence across 12 months. RESULTSPatients included 139 diverse, rural adults (mean age 52.6 6 9.5 years; 72% black; BMI 37.0 6 9.0 kg/m 2 ) with T2D (mean HbA 1c 9.6% [81 mmol/mol] 6 2.0%) and comorbid depressive or distress symptoms. Using intent-to-treat analyses, patients in the intervention experienced marginally significant improvements in HbA 1c (20.92 6 1.81 vs. 20.31 6 2.04; P = 0.06) compared with usual care. However, intervention patients experienced significantly greater improvements in RRD (21.12 6 1.05 vs. 20.31 6 1.22; P = 0.001), depressive symptoms (23.39 6 5.00 vs. 20.90 6 6.17; P = 0.01), self-care behaviors (1.10 6 1.30 vs. 0.58 6 1.45; P = 0.03), and medication adherence (1.00 6 2.0 vs. 0.17 6 1.0; P = 0.02) versus usual care. Improvement in HbA 1c correlated with improvement in RRD (r = 0.3; P = 0.0001) and adherence (r = 20.23; P = 0.007). CONCLUSIONSTailored CBT with lifestyle counseling improves behavioral outcomes and may improve HbA 1c in rural patients with T2D and comorbid depressive and/or RRD symptoms.

OBJECTIVETo evaluate the impact of comorbid depressive symptoms and/or stress on adverse cardiovascular (CV) outcomes in individuals with diabetes compared with those without diabetes.RESEARCH DESIGN AND METHODSInvestigators examined the relationship between baseline depressive symptoms and/or stress in adults with and without diabetes and physician-adjudicated incident CV outcomes including stroke, myocardial infarction/acute coronary heart disease, and CV death over a median follow-up of 5.95 years in the national REGARDS cohort study.RESULTSSubjects included 22,003 adults (4,090 with diabetes) (mean age 64 years, 58% female, 42% black, and 56% living in the southeastern “Stroke Belt”). Elevated stress and/or depressive symptoms were more common in subjects with diabetes (36.8% vs. 29.5%; P < 0.001). In fully adjusted models, reporting either elevated stress or depressive symptoms was associated with a significantly increased incidence of stroke (HR 1.57 [95% CI 1.05, 2.33] vs. 1.01 [0.79, 1.30]) and CV death (1.53 [1.08, 2.17] vs. 1.12 [0.90, 1.38]) in subjects with diabetes but not in those without diabetes. The combination of both elevated stress and depressive symptoms in subjects with diabetes was associated with a higher incidence of CV death (2.15 [1.33, 3.47]) than either behavioral comorbidity alone (1.53 [1.08, 2.17]) and higher than in those with both elevated stress and depressive symptoms but without diabetes (1.27 [0.86, 1.88]).CONCLUSIONSComorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes.

The innovation of the implantable cardioverter defibrillator (ICD) represents a modern medical achievement with substantial life-saving benefits for patients at risk for potentially life-threatening arrhythmias. Over a decade of research resulted in the first ICD implantation in 1980, dramatically changing the face of cardiac care. The introduction of the device was met by skepticism and outright rejection by some, yet large-scale clinical trials clearly demonstrated the mortality benefit of the ICD. Today, specific challenges for this technology have emerged, including barriers to individual and social acceptance of the ICD as a viable form of technology, as well as psychosocial adjustment difficulties and fears in patients. To address these challenges, scientific research, improved communication regarding devices and psychosocial interventions have been developed and extended to this patient population. As such, it is hypothesized that the future will hold expanding indications for ICD implantation, while further meeting patients' medical and psychosocial adjustment needs. The purposes of this paper are to review the history of ICD innovation, describe past and present research on psychosocial adjustment to the ICD, and corresponding psychosocial interventions, analyze individual and social acceptance and utilization of device technology, and forecast future applications and developments of the ICD.

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