The author discusses 3 variables that assess different aspects of social relationships—social support, social integration, and negative interaction. The author argues that all 3 are associated with health outcomes, that these variables each influence health through different mechanisms, and that associations between these variables and health are not spurious findings attributable to our personalities. This argument suggests a broader view of how to intervene in social networks to improve health. This includes facilitating both social integration and social support by creating and nurturing both close (strong) and peripheral (weak) ties within natural social networks and reducing opportunities for negative social interaction. Finally, the author emphasizes the necessity to understand more about who benefits most and least from socialconnectedness interventions.

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Social relationships and health.

The detection of psychiatric illness by questionnaire

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy.

https://cdr.lib.unc.edu/downloads/9p290c48k

ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)

ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1999 guidelines for coronary artery bypass graft surgery)

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(97)02142-9.pdf

Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction

Based on evidence that life stress is a precursor of ischemic heart disease episodes, a randomized control trial of a stress monitoring and intervention program was instituted involving 453 male myocardial infarction patients. Program patients were monitored monthly by telephone for 1 year using the General Health Questionnaire. Whenever a patient's score rose above a critical level, he received a variety of interventions aimed at stress reduction. Results showed that the treated group registered a greater decline in stress scores than controls and, although rehospitalizations and their durations did not differ, there were significantly fewer deaths in the monitored group. It is suggested that stress-relieving programs may have a greater impact in reducing cardiac deaths than in preventing nonlethal coronary episodes.

The ischemic heart disease life stress monitoring program: impact on mortality.

This study examines patient outcomes up to seven years after a one-year, post-myocardial infarction (MI) stress monitoring and management program. A previous randomized controlled trial involving 461 male patients demonstrated that the program lowered stress scores and reduced one-year cardiac deaths by almost 50%, but made no difference in readmission rates or durations. The present study used medical records to assess the durability of these outcomes. Results indicated that the difference in cardiac deaths was primarily due to out-of-hospital deaths (that is, those that were more likely to have been sudden deaths) and persisted for six months beyond the end of the program, after which the mortality curves began to approach one another. In addition, although during the program year MI recurrences occurred at the same rate in the two groups, during the years after the program there were fewer MI recurrences among the treated patients. Over the full follow-up period the group difference in MI recurrences was statistically significant (p = 0.043). Results are considered in terms of methodological limitations of the study, including the timing of randomization, sample selection requirements, and group differences on baseline variables. Findings are also discussed in relation to the outcomes of other programs producing long-term reductions in recurrences or deaths from ischemic heart disease. It is suggested that, regardless of their approach, all such programs may share a common therapeutic mechanism: the provision of emotional support during a period of high vulnerability to stress.

Long-term follow-up of the ischemic heart disease life stress monitoring program

Life stress, denial and outcome in ischemic heart disease patients

This paper attempts to identify the therapeutic components responsible for the mortality-reducing impact of the Ischemic Heart Disease Life Stress Monitoring Program. Designed to break the link between stress and illness, this one-year intervention program for patients recovering from myocardial infarctions included monthly telephone monitoring of psychological symptoms of stress and home nursing visits for high stress patients. Nursing interventions were individually tailored for each patient and involved a combination of teaching, support and referral strategies. A randomized controlled trial of the program. involving 453 male patients showed that it reduced stress symptoms and cut one-year mortality rates by 50%. These results are considered in the context of the approaches and outcomes of other educational and support programs for cardiac patients. In addition to sample size two factors appear to differentiate the program from other less successful therapies: patient selection for treatment o...

Raymond Prince

Papers

Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction

The ischemic heart disease life stress monitoring program: impact on mortality.

Long-term follow-up of the ischemic heart disease life stress monitoring program

Life stress, denial and outcome in ischemic heart disease patients

The ischemic heart disease life stress monitoring program: Possible therapeutic mechanisms