Psycho-Cardiology in Israel

Although major advances in treatment have contributed to a higher rate of cardiac event survival, cardiovascular diseases (CVD) are still a leading cause of death in Israel, as in the U.S., and in the majority of European countries

(Israel Bureau of Statistics, 2012). Israel’s population currently numbers 7.8 million people,75% of whom are Jews and 25% Arabs (Statistical Abstract of Israel, 2012). In 2009, 6,500 people in Israel died as a result of CVD: 16.8% of the total number of deaths that year (Israel Bureau of Statistics, 2011). As for morbidity, more than 10,000 people arrived at hospitals in Israel for the treatment of Acute Coronary Syndrome in 2010 (ACSIS, 2010).

 

 

There are 24 cardiology departments in hospitals in Israel; however, only six include a psychologist who functions either as an integral part of the department's team or as an on-call consultant. Psychologists who treat cardiac patients in Israel must complete at least a Master's degree in either clinical, health or rehabilitation psychology, as well as four years of clinical training. During this internship, trainees acquire knowledge and expertise in psychological diagnosis and in psychotherapy methods such as CBT, supportive, psychodynamic, and short term psychotherapies. Every trainee is required to be under supervision for 200 therapy hours and to work with at least two different patient populations. After completing four years of internship and passing a final oral exam, he/she is entitled to see patients without supervision and has earned the title of certified psychologist. 

 

 

The main goal of psychologists working in cardiology departments is to improve patients' and family members' wellbeing. Practitioners initially assess patients to detect severe psychological difficulties – such as reactive or chronic depression, anxiety and stress – and then generally suggest CBT-oriented or supportive short term interventions, including the use of relaxation techniques, biofeedback and guided imagery. Psychologists also address issues of motivation and adherence difficulties, especially with regard to smoking cessation, diet and exercise.



Interventions are provided mostly via individual psychotherapy, but also by dyadic consultations and group sessions. Only a few places provide additional long-term therapies, which are for the most part dynamically or narratively oriented. Most of the cardiac patients treated by psychologists have had a myocardial infarction (MI); however, tailored interventions are also provided for heart failure patients and those who are awaiting or coping with the consequences of coronary artery bypass graft surgery (CABG) or have received an implantable cardioverter defibrillator (ICD). 

 

A great deal of research is being done in Israel in the field of psycho-cardiology.  A few highlights: Drory's team implemented an extensive follow- up study of cardiac patients in Israel (13 years) and reported that neighborhood socioeconomic status (SES) is strongly associated with long-term survival after MI (Gerber, Benyamini, Goldbourt & Drory, 2010). Groundbreaking studies on burnout as a risk factor for  CVD were published by Melamed and Shirom and summarized in their extensive review in Psychological Bulletin (Melamed , Shirom,  Toker, Berliner, & Shapira, 2006). Many studies on MI patients have focused on cardiac-induced PTSD. In fact, research on PTSD and heart disease was pioneered in Israel by Dr. Ilan Kutz who, with his colleagues, may have been the first to identify post-traumatic stress symptoms among cardiac patients (Kutz, Garb & Davis, 1988). Shemesh's studies reported that MI patients with PTSD are less adherent to medication-taking (2001), and were more than twice as likely to be re-hospitalized due to cardiovascular causes during the study period (2004). Kark (Kark, Fink, Adler, Goldberger & Goldman, 2006; Kark, Gordon, & Haklai, 2000), has consistently shown the disturbing gap in Israel between Arab and Jewish cardiac patients in terms of morbidity, mortality and health-promoting behaviors. Finally, Vilchinsky and her colleagues focused on the crucial role a couple's relationship has on coping with CVD and showed that support perceptions among couples coping with cardiac illness were associated not only patients' mood but also their LDL levels and smoking cessation six-months post-MI (Vilchinsky et al., 2011).

 

 

Finaly, Israel has unfortunately been subject to political instability, war and terrorism for many years and there is evidence of the toll that these circumstances take on the population's cardiac health. For example, during the first days of the Gulf War in 1991, which consisted of Iraqi missile attacks on Israel, a sharp rise in the prevalence of acute Ml and sudden death was noted compared with five control periods. Interestingly, despite the continuing missile threat, the incidence of acute Ml returned to normal after the initial phase of the war (Meisel et al., 1991). Yet, the effect of living under these stressful circumstances on coping with cardiac illness has not been exhaustively explored.  

 

 

  References 

*ACSIS (2010). Acute Coronary Syndrome Israeli Survey March-April 2010. Survey findings and temporal trends 2000-2010.The Israeli center for Disease Control (Publication 337). 
*Gerber, Y., Benyamini, Y., Goldbourt, U., & Drory, Y. (2010). Neighborhood socioeconomic context and  long-term survival after Myocardial Infarction. Circulation, 121, 375-383

*Israel Bureau of Statistics, 2012.Retrieved 26.03.2013: http://www.cbs.gov.il/shnaton63/st02_01.pdf

*Kark, J.D., Fink, R., Adler, B., Goldberger, N., & Goldman, S. (2006). The incidence of coronary heart disease among Palestinians and Israelis in Jerusalem. International Journal of Epidemiology, 35, 448-57. 

*Kark, J.D., Gordon, E.S., & Haklai, Z. (2000). Coronary heart disease mortality among Arab and Jewish                 residents of Jerusalem. Lancet, 356, 1410-1. 

*Kutz, I., Garb, R., & David, D. (1988). Post-Traumatic Stress Disorder Following Myocardial Infarction. General Hospital Psychiatry, 10, 169-176. 

*Meisel, S.R., Dayan, K.I. Pauzner, H. Chetboun, I. Arbel, Y. David, D. Kutz, I.(1991). Effect of Iraqi missile war on incidence of acute myocardial infarction   and sudden death in Israeli civilians. Lancet, 338, 660- 661.